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HX641 27982 
RC625  .N59  1916   Pellagra,  an  America 


Case  of  pellagra,  showing  typic  "  gauntlet."     (Patient  of  Dr.  G.  A.  Zeller.) 


PELLAGRA 

AN  AMERICAN  PROBLEM 

BY 

GEORGE  M.   NILES.   M.D. 

GASTRO-ENTEROLOGIST     TO     THE     GEORGIA     BAPTIST     HOSPITAL,      WESLEY 

MEMORIAL     HOSPITAL,     AND     ATLANTA     HOSPITAL;      CONSULTING     GASTRO- 

ENTEROLOGIST  TO  THE    ATLANTA  ANTITUBERCULOSIS  ASSOCIATION  AND    TO 

THE  MOORE  MEMORIAL  CLINIC,  ATLANTA,   GEORGIA 

SECOND  EDITION 

ILLUSTRATED 

PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS    COMPANY 

1916 

./  ^ 


^-^ 


/ 


Copyright,    igi2,   by   W.    B.    Saunders    Company. 
Reprinted    October,    1912.      Revised,    re- 
printed, and   recopyrighted 
January,  1916 


Copyright,  1916,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 
B.     SAUNDERS     COMPANY 
PHILADELPHIA 


TO 

CHARLES   E.  BOYNTON,  A.  B.,  M.  D., 

THIS   VOLUME   IS   INSCRIBED 

AS   A   TRIBUTE   TO    HIS   HIGH    PROFESSIONAL 

ATTAINMENTS   AND   IN  REMEMBRANCE 

OF  HIS  MANY  ACTS  OF  KINDNESS, 

BY   THE  AUTHOR 


PREFACE  TO  THE  SECOND  EDITION 


The  success  of  the  first  edition  of  this  book  seemed  to 
indicate  that  it  filled  a  need  of  the  profession.  In  this 
second  edition  many  changes  and  additions  have  been 
made,  bringing  the  consideration  of  Pellagra  as  a  national 
problem  up  to  our  present  state  of  knowledge. 

The  chapter  on  Etiology  contains  the  result  of  the  inves- 
tigations of  Dr.  Joseph  Goldberger,  Special  U.  S.  Agent  for 
the  study  of  this  disease,  and  the  Thompson-McFadden 
Pellagra  Commission,  whose  careful  and  scientific  labors 
have  received  deserved  commendation.  The  efforts  of 
other  students  have  also  been  recognized. 

The  chapter  on  Treatment  contains  a  number  of  late 
therapeutic  suggestions,  including  the  employment  of  em- 
etin  for  the  frequently  ameba-infected  mouth  and  intes- 
tines, the  scarlet  ointment  for  obstinate  dermatitis,  and 
others,  which  I  have  found  helpful. 

I  am  indebted  to  numerous  friends  for  criticisms  and  con- 
structive advice;  and  especially  to  the  members  of  the 
Thompson-McFadden  Commission,  who  have  both  officially 
and  personally  extended  valuable  aid,  is  offered  grateful 
acknowledgment. 

While  the  causation  of  Pellagra  is  not  yet  entirely  proved, 
the  conviction  is  expressed  that  we  are  much  nearer  the 
goal  of  etiologic  certaint}^,  pathologic  assurance,  and  conse- 
quent therapeutic  confidence. 

George  M.  Niles. 

920  Candler  Building, 

Atlanta,  Ga. 
Jamiary,  igi6. 


Digitized  by  the  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/pellagraamericanOOnile 


PREFACE 


In  presenting  this  work  I  feel  that  a  Hterature  on  the 
subject  of  pellagra  should  be  advanced  by  American  ob- 
servers. 

We  should  not  be  deterred  because  of  its  recent  visita- 
tion, nor  should  we  be  content  to  leave  its  investigation 
to  our  friends  in  Europe,  though  they  have  been  wrestling 
with  this  problem  for  near  two  centuries ;  and  we  may  find 
it  difficult  to  rival  them  in  erudition  as  well  as  the  profund- 
ity with  which  they  have  considered  some  of  the  unsolved 
pathologic  and  etiologic  questions.  A  condition  confronts 
us,  and  we  must  needs  be  up  and  doing  in  order  to  meet  it. 

I  have  no  apology  to  offer  for  expressing  my  candid 
opinions  and  firm  convictions.  Should  subsequent  experi- 
ence and  knowledge  convince  me  that  I  have  fostered  error, 
I  shall  be  the  first  to  announce  it  and  make  the  necessary 
amends.  No  advancement  has  ever  been  made  except  by 
following  a  new  idea  to  an  established  fact,  and  in  the  light 
which  is  now  guiding  me  I  can  see  no  incorrect  premise  nor 
any  false  conclusions;  yet  I  do  not  expect  the  approbation 
of  all  whose  opinions  I  court  and  whose  words  I  respect. 

To  go  forward  and  not  backward  in  the  management  of 
this  threatened  scourge  will  require  much  cHnical  observa- 
tion, much  laboratory  labor,  special  technic  in  the  examina- 
tion and  treatment  of  the  various  phases  of  pellagra,  a 

7 


8  PREFACE 

practical  knowledge  of  physiology  and  physiologic  chem- 
istry, the  medical  uses  of  special  drugs,  baths,  waters,  and 
electricity,  and,  with  it  all,  time  and  patience. 

It  will  be  most  interesting  a  few  years  hence  to  look  back 
in  a  retrospective  manner  on  the  efforts  of  to-day,  on  the 
possibly  erroneous  viewpoints  with  which  we  have  consid- 
ered pellagra,  and  our  somewhat  halting  footsteps  in  its 
therapeutics.  We  are  glad  in  this  connection,  however,  to 
lay  to  our  souls  the  flattering  unction  that  our  efforts  are  at 
least  sincere  and  justified  by  present  results. 

To  many  kind  friends  I  convey  my  appreciation  for  help- 
ful suggestions  and  other  courtesies;  but  particularly  do  I 
wish  to  thank  Dr.  J.  W.  Babcock,  of  Columbia,  and  Dr.  C. 
H.  Lavinder,  of  the  PubHc  Health  and  Marine-Hospital  Ser- 
vice, for  both  their  encouragement  and  consideration. 

To  the  medical  profession  I  offer  this  book  for  what  it  is, 
not  claiming  that  it  speaks  the  "'last  word,"  but  that  it  rep- 
resents the  labors  of  a  student  who  is  endeavoring  \\dth  a 
spirit  of  courage  and  optimism  to  contribute  a  worthy  por- 
tion to  the  sum  total  of  our  information  concerning  pellagra, 
this  American  problem. 

George  M.  Niles. 

920  Caxdler  Buildikg, 
Atlanta,  Ga. 


CONTENTS 


CHAPTER  I 

PAGE 

General  Considerations,  Historic  and  Otherwise ii 


CHAPTER  II 
Pellagra  in  the  United  States 25 

CHAPTER  III 

A  Discussion  of  the  Etiology  of  Pellagra 34 

CHAPTER  IV 

Symptomatology  and  Clinical  Coltrse  of  Pellagra 77 

CHAPTER  V 

Clinical  Reports  and  Description  of  Cases  of  Pellagra  from 

Different  Sources 132 

CHAPTER  VI 

Pathology  and  Morbid  Anatomy  of  Pellagra 154 

CHAPTER   VII 
Diagnosis,  Coxjrse  and  Progress,  and  Prognosis  of  Pellagra..  168 

CHAPTER  VIII 

The    Treatment    of    Pellagra— A    Discussion    of    Different 

Methods 184 

9 


lO  CONTENTS 

CHAPTER  IX 

PAGE 

The  Prophylaxis  of  Pellagra 213 

CHAPTER  X 

Descriptions   of  Some   Recent  Experiments   on   Animals,  and 

Deductions  Therefrom • 231 


Bibliographic  Index 249 

Index , , 253 


PELLAGRA 


CHAPTER  I 


GENERAL    CONSIDERATIONS,   HISTORIC    AND 
OTHERWISE 

Pellagra,  as  an  American  problem,  is  now  receiving 
marked  attention  in  many  sections  of  this  country.  Up 
to  less  than  eight  years  ago  it  appeared  upon  the  sociologic 
horizon  as  a  cloud  no  larger  than  a  man's  hand,  but  it 
has  continued  to  grow  and  expand,  until  at  present  it 
looms  up  before  the  sober  observer  with  portentous 
solemnity. 

Pellagra  may  be  defined  as  an  endemic  malady,  char- 
acterized by  an  erythema  (generally  symmetric)  upon  the 
exposed  surfaces  of  the  body,  by  gastro-intestinal  dis- 
turbances, and  by  nervous  and  psychic  phenomena. 

This  definition  is  necessarily  incomplete,  for  to  de- 
scribe this  protean  disease  in  a  few  words  would  require 
the  graphic  imagination  of  a  Carlyle,  or  the  word-paint- 
ing of  a  Macaulay. 

The  synonyms  for  pellagra  are  numerous,  among  which 
are  Alpine  Scurvy,  Asturian  Leprosy,  Asturian  Rose,  Dis- 
ease of  the  Landes,  Maidismus,  Psychoneurosis  Maidica, 

11 


12  PELLAGRA 

Mai  de  la  Rosa,  Mai  del  Sole,  Mai  de  Misere,  Mai  del 
Padrone,  and  many  others. 

To  Frapolli  we  owe  the  present  name  of  the  disease 
{pelle,  skin,  and  agra,  rough),  and  the  same  writer  de- 
clared that  the  disease  was  an  ancient  one,  and  none 
other  than  the  sickness  pellarella,  which  was  noted  in 
1578  by  the  authorities  of  the  Hospital  Major,  of 
Milan. 

As  to  the  pronunciation,  the  varieties  are  almost  legion. 
It  would  seem  fair  to  permit  a  man  the  privilege  of  pro- 
nouncing his  own  name;  or  to  the  resident  of  a  state  or 
country  the  like  privilege  of  pronouncing  the  name  of 
his  abode.  For  instance,  we  grant  to  the  residents  of 
Iowa  the  right  to  say  loway,  or  to  those  living  in  Arkansas 
the  rather  bizarre-sounding  Arkansaw.  By  this  same 
token  it  seems  proper  to  permit  the  Italians,  who  gave  us 
the  name,  to  also  teach  us  the  pronunciation.  After  con- 
sulting with  not  a  few,  but  with  many  educated  ItaHans, 
those  in  a  position  to  speak  with  authority,  the  wTiter  is 
convinced  that  the  most  widely  accepted  pronunciation 
gives  the  a  in  pellagra  the  same  sound  as  in  the  word 
father,  with  the  accent  on  the  second  syllable. 

Some,  of  course,  will  take  issue  with  this,  as  would  be 
the  case  -with  any  other  word  not  possessing  the  sanction 
of  ancient  and  world-wide  custom  in  its  pronunciation; 
but  the  sound  of  a  in  this  word,  as  given  above,  is  prob- 
ably used  more  than  any  other. 

To  trace  back  the  history  of  this  disease,  among  the 
rather  scattered  archives  of  the  middle  ages,  is  both  in- 
teresting and  difficult.  Dr.  Howard  D.  King,  of  New  Or- 
leans, recently  contributed  a  most  valuable  historic  study 


GENERAL  CONSIDERATIONS,  HISTORIC  AND  OTHERWISE   13 

of  pellagra,  and  to  him,  as  well  as  to  Dr.  A.  Marie,  we  are 
indebted  for  much  of  this  data. 

To  weave  a  history  of  pellagra  without  encountering 
the  visage  of  maize  seems  almost  impossible.  Through 
the  tangled  skein,  as  it  is  interwoven  with  the  destinies  of 
several  nations  and  peoples,  we  see  the  rise  and  decline 
of  pellagra  almost  coincident  with  the  consimiption  of 
Indian  corn;  and,  try  as  we  may,  we  cannot  disassociate 
the  two. 

In  1600  Baruino,  in  a  medical  treatise,  called  attention 
to  a  pecuUar  malady  prevailing  among  certain  tribes  of 
the  American  Indians.  From  his  incomplete  description, 
it  apparently  resembled  the  pellagra  of  to-day.  Even 
then  he  ascribed  it  to  the  use  of  corn,  which  the  Indians 
used  constantly  as  a  part  of  their  diet. 

Francisco  Scipione,  an  Italian  poet,  archeologist,  and 
litterateur,  also  described  a  similar  disease  but  a  few  months 
after  Baruino,  his  description  being  much  more  com- 
plete. About  this  time  there  was  also  noted  a  peculiar 
disease  among  horses,  in  which  those  animals  seemed 
both  paretic  and  tabetic,  showing  a  malnutrition  with 
loss  of  hair.  This  was  supposed  to  have  been  produced 
by  feeding  them  spoiled  corn. 

In  Spain  corn  was  introduced  as  an  article  of  food  in 
the  period  between  1680  and  1700.  Strange  to  say,  the 
first  authentic  accounts  of  pellagra  appeared  just  about 
this  time.  According  to  Babes  and  Sion,  as  claimed  by 
Dr.  Babcock,  it  is  probable  that  pellagra  appeared  in 
Europe  long  before  its  scientific  description,  but  was 
classed  as  either  gastro-intestinal,  or  nervous,  or  mental. 
or  leprous,  or  scorbutic  diseases.     It  is,  therefore,  some- 


14  PELLAGR.^ 

what  difficult  to  determine  whether  or  not  pellagra  ap- 
peared in  Europe  before  the  advent  of  Indian  corn  as  a 
food. 

The  first  really  scientific  account  is  ascribed  to  Caspar 
Casal,  who,  in  1735,  observed  it  in  the  vicinity  of  0\'iedo. 
Several  years  later  he  wrote  of  it  fully,  describing  it  as 
seen  in  the  Asturias,  and  giving  it  the  name  "Mai  de 
Rosa."  For  a  long  time  the  disease  was  found  only  in 
this  region,  and  in  somewhat  narrow  limits.  Even  to 
this  day  Oviedo  seems  a  focus. 

In  Italy  it  appeared  about  twenty-five  years  later  than 
in  Spain.  FrapoUi,  to  whom,  as  previously  said,  we  are 
indebted  for  the  word  pellagra,  believed  he  had  found 
a  picture  of  pellagra  in  the  description  of  la  pellarella  in 
1578.  This  was  more  probably  a  case  of  s}^hilis.  About 
the  time  Frapolli  named  it,  Adoardi,  of  Venetia,  called 
it  "scorbutus  alpinus." 

By  1776,  also  a  notable  year  in  American  annals,  the 
disease  had  spread  to  such  an  extent  that  the  Venetian 
authorities,  at  the  request  of  the  Sanitary  Commission 
of  Venice,  issued  an  edict  prohibiting  the  sale  or  exchange 
in  the  pubHc  markets  of  corn  ha\dng  a  bad  odor  or  taste, 
or  which  was  discolored.  Even  at  that  time,  exacerba- 
tions and  remissions  of  pellagra  during  different  seasons 
of  the  3'ear  were  noted,  for  D'Oleggio,  in  1784,  suggested 
the  term  "vernal  insolation,"  meaning  the  "sunburn  of 
spring."  Also  in  that  year  a  special  hospital  for  those 
afiiicted  in  this  manner,  and  for  special  study  of  the  dis- 
ease, was  established  in  Legano  by  royal  warrant,  and 
called  the  Joseph  II  Pellagra  Asylum.  The  elder  Stram- 
bio,  a  man  admirably  fitted  by  both  education  and  tem- 


GENERAL  CONSIDERATIONS,  HISTORIC  AND  OTHERWISE   15 

perament  for  such  a  position,  was  appointed  chief  physi- 
cian. 

From  this  period,  up  to  1839,  but  little  was  done  to 
check  the  ravages  of  pellagra,  when  Ballardino  declared 
that  it  was  produced  by  eating  damaged  maize,  claiming 
that  he  had  demonstrated  it  beyond  a  peradventure. 
His  views,  as  happens  to  any  one  making  radical  state- 
ments, met  with  ridicule,  and,  while  the  discussion  waxed 
warm,  the  flames  of  the  disease  spread  with  amazing  rapid- 
ity. From  1839  to  1856,  a  space  of  seventeen  years,  there 
was  an  increase  of  from  14  to  28  per  thousand,  or  from 
20,282  to  38,777.  This  alarming  increase  brought  the 
Lombard  government  to  action,  and  it  was  high  time. 
A  commission  from  the  Institute  Lombardo  was  appointed 
to  investigate,  and  to  report  ways  and  means  to  combat 
this  state  of  affairs.  Commissions,  like  petit  juries,  are 
often  remarkable  bodies,  and  this  was  no  exception.  They 
reported  that  while,  in  their  opinion,  Ballardino's  theory 
as  to  spoiled  or  damaged  maize  being  a  causative  factor 
was  in  the  main  correct,  they  did  not  believe  that  a  diet 
free  from  maize  would  either  exert  a  favorable  influence 
or  prevent  the  disease. 

It  would  appear  that  there  were  then,  as  in  this  day, 
factional  differences  among  the  bodies  of  thought, 
where,  unfortunately,  prejudice  was  permitted  to  blind 
sober  judgment,  and  personal  animus  to  warp  scientific 
conclusions. 

This  commission,  therefore,  attributed  the  improve- 
ment in  the  afHicted  peasantry,  not  to  elimination  of 
corn  as  a  food,  but  more  hygienic  methods  of  living. 

'Twas  ever  thus. 


l6  PELLAGIL\ 

To  give  an  idea  of  the  amazing  spread  of  pellagra  during 
those  years,  it  might  be  mentioned  that,  in  the  pro\dnce 
of  Vicenzo,  the  number  of  known  pellagrins  between  1853 
and  1855  was  1380;  in  i860.  2974;  and  1879,  3400.  These 
figures  covered  only  one  pro\'ince. 

In  1879  it  was  estimated  that  the  number  of  peasants 
suffering  ^^•ith  pellagra  had  reached  the  appalling  number 
of  97.855,  being  distributed  as  follows:  Lombardy,  40.838; 
Venetia,  29,386;  Emilia,  18,728;  Tuscany.  4382;  Marches 
and  Umbria,  2155;  Piedmont,  1692;  Liguria.  148;  Rome,  76. 

In  Lombardy,  where  the  disease  always  seemed  to  flour- 
ish most,  the  worst  infected  centers  were  Buscia.  Pavia, 
Piancenza.  and  Ferrara.  Xext  to  Lombardy,  it  was  most 
severe  in  Venetia  and  Emilia.  In  these  three  pro\dnces 
the  number  of  pellagrins  in  1880  formed  about  30  per 
1000  of  the  whole  agricultural  population.  This  was  also 
reflected  in  the  militan.-  reports  from  those  pro^■inces,  for 
from  18  to  20  per  cent,  of  the  conscripts  were  reported 
unlit  for  duty  on  account  of  illness  of  this  character. 
Furthermore,  in  Italy,  there  were,  in  1874.  945  pellagrous 
lunatics.     In  1877  there  were  1348. 

The  years  1871  to  1884  showed  the  "high-water  mark" 
of  this  disease,  104,067  being  ofliciaUy  reported.  There 
was  but  little  fluctuation  in  the  figures  until  1899,  when 
there  appeared  a  noticeable  dechne  among  the  afflicted 
peasantry-. 

In  a  goverrmient  report  "Analli  di  Agricoltura,  No.  18," 
which,  to  an  extent,  corresponds  to  the  bulletins  issued 
by  our  Public  Health  and  Marine  Hospital  Service,  is 
published  the  melancholy  pellagra  statistics  for  the  St. 
Clement's  Hospital  of  Venice  for  a  period  of  six  years 


GENERAL  CONSIDERATIONS,  HISTORIC  AND  OTHERWISE   1 7 

preceding,  and  it  shows,  with  frightful  distinctness,  the 
extent  of  the  "el  delirio  della  miseria,"  as  the  Italians 
call  it: 

Total  number  insane.  Pellagrous  insane. 

1874 558  178 

1875 595  153 

1876 666  175 

1877 802  215 

1878 859  294 

1879 924  337 

Total 4404  1352 

In  1884  conservative  estimates  placed  the  number  of 
pellagrins  in  Italian  hospitals  and  insane  asylums  at 
10,000,  and  the  civic  burden  was  so  onerous  that  a  bill, 
aimed  at  the  prevention,  was  introduced  in  the  Chamber  of 
Deputies  at  Rome  through  the  efforts  of  the  ZannardelH 
cabinet  in  1902. 

In  1903  there  were  thought  to  be  about  60,000  cases  in 
Italy  proper,  though  some  of  the  statistics  were  unreliable. 
The  last  census  of  1905  shows  but  55,000  pellagrins  in  that 
country,  and  well-posted  observers  consider  that  this  number 
has  remained  almost  stationary  up  to  the  present  date. 

There  are  several  reasons  mentioned  by  Dr.  L.  W. 
Sambon  which  militate  against  correct  reports;  the  pa- 
tient does  not  always  admit  having  pellagra;  there  is  no 
compulsion  requiring  the  authorities  to  be  notified;  and, 
not  the  least  important,  is  the  fact  that  local  pride  and  a 
desire  to  show  a  decrease  in  a  given  locality  cause  the 
knowledge  of  some  cases  to  be  suppressed.  Sambon, 
therefore,  thinks  that  at  present  a  fair  estimate  of  pella- 
grins in  Italy  would  be  100,000,  though  he  admits  that 
the  mortahty  is  not  near  so  great  as  formerly.  This 
briefly  but  fairly  covers  the  situation  in  Italy. 
2 


i8  PELLAGRA 

In  France,  too,  pellagra  has  wielded  an  important 
place  in  history.  First  reported  in  the  vicinity  of  Arca- 
chon  in  Gascony  in  1818,  it  steadily  spread  along  the 
coast  of  the  Gironde  and  the  Landes.  Marchand,  in  1826, 
called  attention  to  its  prevalence  in  the  southern  prov- 
inces of  France.  Dr.  Petit,  an  observing  French  physi- 
cian, of  that  locaHty,  noted  it  about  1828,  stating  that 
it  was  more  common  in  the  Landes  than  in  the  Gironde 
district,  and  that  at  one  time  there  were  about  200  cases 
in  a  population  of  6000. 

According  to  Dr.  C.  H.  Lavinder,  it  was  first  observed 
in  France  by  the  elder  Hameau  in  the  vicinity  of  Teste 
in  18 18,  whence  came  the  French  appellation  "maladie  de 
la  Teste." 

From  these  districts,  the  malady  spread  along  the 
left  bank  of  the  river  Garonne  and  toward  the  Pyrenees 
Mountains.  Fortunately  for  the  people  in  the  vicinity  of 
Dax,  the  disease  never  assumed  serious  proportions  there. 

From  1829  to  1880,  pellagra  was  one  of  the  live  sub- 
jects in  the  sociologic  thought  and  literature  of  France. 
But,  as  remarked  by  Regis,  there  suddenly  came  a  silence, 
and  for  the  last  thirty  years  but  few  cases  have  been 
reported.  This  sudden  change  is  hard  to  explain.  Some 
think  that  it  has  simply  disappeared,  "like  the  figment 
of  a  vision,  leaving  not  a  rack  behind";  others  think  that 
there  has  been  estabHshed  a  gradual  irmnunity,  or  that 
the  people  have  become  so  habituated  to  it  that  they 
have  lost  both  interest  and  fear,  viewing  it  wdth  that 
fatalistic  indifference  of  the  Oriental. 

At  any  rate,  pellagra  is  no  longer  noticeable  in  France 
to  any  extent.     Happy  country! 

In  Spain,  according  to  Triller,  in  spite  of  intelligent 


Egyptian  case  of  pellagra,  taken  after  death.     (Courtesy  of  Dr.  F.  N. 

Sandwith.) 


Egyptian  case  of  pellagra,  showing  symmetric  "gauntlet"  and 
"  anklet  ";  also  showing  the  pellagrous  "  breast-plate  "  observed  in  those 
whose  breasts  are  habitually  exposed  to  the  sun.     (Case  of  Dr.  Sandwith.) 


GENERAL  CONSIDERATIONS,  HISTORIC  AND  OTHERWISE   19 

prophylaxis,  this  disease  at  present  affects  fully  20  per 
cent,  of  the  inhabitants  of  certain  provinces.  It  should 
not  be  forgotten  that  here,  in  the  Asturias,  pellagra  was 
first  described  in  1735. 

Casal  spoke  of  the  conditions  there  as  follows:  "Corn 
is  the  principal  food  of  the  laborer  there;  soups  are  made 
of  it,  to  which  they  usually  add  milk;  they  likewise  eat 
eggs,  fish,  and  cheese;  very  rarely  they  buy  fresh  meat 
and  occasionally  salt  meat." 

"Here,  as  elsewhere,  they  begin  by  misconceiving  the 
real  origin  of  the  affection,"  for  different  writers  attempted 
to  prove  that  it  came  from  leprosy.  Their  hypotheses, 
of  course,  were  not  proved. 

In  Roumania  the  first  recorded  case  was  in  1810,  and  it 
seems  comparatively  easy  to  trace  the  progress  of  the  dis- 
ease along  with  the  importation  of  wet  and  damaged  corn 
by  the  inferior  vessels  of  the  coastwise  trade. 

From  the  period  between  1833  to  1846  pellagra  attracted 
much  attention,  and  was  called  by  the  people  "Buba 
Tranjilar." 

Between  1854  and  1859  the  government  began  to  take 
notice,  finding  4500  recognized  cases  in  Moldavia  and 
Wallachia.  In  1885  this  number  had  grown  to  16,260,  and 
in  1886  to  19,797. 

In  1898  the  peasant  population  of  Roumania  was  esti- 
mated at  5,300,000,  and  the  statistics  pointed  to  21,000 
pellagrins  among  this  number. 

In  1906  Triller  thought  there  were  at  least  30,000  there, 
and  in  1907  other  observers  estimated  the  number  at 
40,000. 

Corfu,  one  of  the  Ionian  islands,  famed  in  song  and 
story,  has  also  suffered  the  burden  of  this  affiction.     It 


20  PELLAGRA 

became  epidemic  there  in  1856,  and  at  this  day  exists  in 
30  out  of  the  117  communes.  The  percentage  of  pella- 
grins in  the  whole  population  is  probably  3.2  per  1000 
inhabitants.  Typhaldos,  of  Corfu,  has  given  the  disease 
much  study,  and  from  him  we  have  gotten  some  valuable 
information  from  many  viewpoints. 

Austria  has  not  been  exempt,  for  in  the  Tyrol,  espe- 
cially in  Bukowina,  having  a  population  of  38,000,  2.9  per 
cent,  are  pellagrous.  In  this  region  of  Austria  there  are 
seventeen  institutions,  where  the  peasantry  can  get  proper 
food,  and  receive  instructions  as  to  cooking,  hygiene,  and 
other  helpful  knowledge. 

This  country  has  deeply  considered  the  situation  in  its 
legislative  assemblies,  has  enacted  wise  laws,  restraining 
and  educational,  and  seems  to  have  the  disease  well  in  hand. 

In  Great  Britain,  only  two  cases  were  reported  up  to 
19 13,  one  by  Drs.  Brown  and  Carruthers,  of  Rock  Ferry, 
and  the  other  by  Drs.  R.  Dods  Brown  and  Cranston  Low, 
assistant  physicians  in  the  Royal  Edinburg  Asylum.  Since 
that  date,  however,  Dr.  Sambon  has  discovered  many  pre- 
viously undiagnosed  cases  in  England,  53  being  observed 
in  one  hospital. 

In  Africa,  as  in  other  warm  countries,  this  malady  has 
gained  a  strong  foothold.  It  was  first  recognized  in  1847, 
by  Pruner,  who  had  observed  it  previously  in  Italy. 

Pruner's  statements  did  not  meet  with  a  favorable 
reception,  for  Hirsh  and  others  "laughed  him  to  scorn." 
Nothing  further  was  said  or  done,  until  1892,  when,  at  a 
medical  congress  held  at  Cairo,  Dr.  F.  N.  Sandwith,  senior 
physician  and  lecturer  on  medicine,  Kasr-el-Ainy  Hospital, 
Cairo,  read  a  splendid  paper  on  pellagra  and  its  prevention. 


GENERAL  CONSIDERATIONS,  HISTORIC  AND  OTHERWISE  21 

He  stated  that,  through  the  courtesy  of  Dr.  J.  Warnock, 
superintendent  of  the  lunatic  asylum  of  that  region,  he 
saw  40  or  50  pellagrous  lunatics.  Since  1893,  Dr.  Sand- 
with  has  seen  more  than  iioo  cases,  and  asserts  that  it  is 
quite  prevalent  in  Lower  Egypt,  though  not  so  much  in 
Upper  Egypt.  He  thinks  that  the  proportion  of  those 
who  lose  their  minds  is  not  so  large  in  Egypt  as  in  Italy, 
though  unable  to  explain  why. 

Dr.  C.  H.  Lavinder,  who  has  studied  in  Egypt  also, 
rather  differs  from  some  of  Dr.  Sandwith's  conclusions, 
mainly  as  to  its  sHght  prevalence  in  Upper  Egypt. 

Leaving  for  a  time  the  consideration  of  this  disease 
among  the  congested  populations  of  the  "Old  World," 
we  come  nearer  home,  and  still  do  we  find  the  hideous  face 
of  this  specter  confronting  us  at  every  stage  of  our  in- 
vestigations. Suffice  it  to  say,  that  hardly  a  country  in 
Southern  Europe  has  escaped,  for  Algeria,  Tunis,  Bul- 
garia, Servia,  Portugal,  Dalmatia,  Croatia,  Bosnia,  Tur- 
key, and  even  as  far  north  as  Poland,  where  freedom 
shrieked  when  Kosciusco  fell,  do  we  find  it. 

It  will  be  most  interesting  to  note  the  effect  on  the  future 
prevalence  of  pellagra  that  may  result  from  the  European 
war  now  raging.  These  enlightening  facts  must,  of  neces- 
sity, be  left  to  the  historian  of  a  later  day. 

In  Jamaica,  in  1888,  Dr.  Henry  Strachan,  senior  medical 
officer,  reported  510  cases  of  "malarial  multiple  neuritis," 
observed  in  the  Kingston,  Jamaica,  Public  Hospital,  and 
on  121  of  these  patients  full  notes  were  taken. 

"The  patients  complained  of  numbness  and  burning 
heat  in  the  palms  and  soles,  often  accompanied  by  cramps, 
worse  at  night  and  in  wet  weather.     Impaired  vision  and 


22  PELLAGRA 

hearing  were  noted,  and  a  feeling  of  constriction  around 
the  lower  part  of  the  chest.  An  eczematous  condition  ap- 
peared on  the  tops  of  the  eyehds,  the  angles  of  the  mouth, 
and  the  mucocutaneous  margins  of  the  nostrils;  the  lips 
were  usually  red,  and  the  palms  hot  to  the  touch  and 
hyperemic.  Later,  motor  pains  of  upper  and  lower  ex- 
tremities appeared.  Pain  was  constant,  especially  of  the 
feet.  Emaciation  developed  with  the  progress  of  the  dis- 
ease. Pigmentation  of  the  palms,  lips,  and  soles  was  pres- 
ent ;  respiration  was  impaired,  and  death  ensued  from  paral- 
ysis of  the  respiratory  muscles.  Death  was  rare,  recov- 
ery being  the  rule. 

"Soreness  of  the  mucocutaneous  borders,  i.  e.,  eyehds, 
lips,  urethra,  anus,  vulva,  etc.,  was  almost  the  first  symptom. 
Wasting  and  contraction  of  the  muscles  was  very  marked 
in  extreme  cases,  the  'claw  hand'  and  foot  being  pro- 
nounced features.  ...  In  the  last  stage,  when  the 
patient  is  greatly  wasted,  there  may  be  delusions  with 
feeble  attempts  at  violence.  In  this  condition  they  may 
be  committed  to  asylums. 

"The  eyelids  are  red  and  irritated;  a  slightly  eczematous 
condition  develops  at  the  corners  of  the  mouth  and  round 
the  margin  of  the  nostrils,  with  a  fine  branny  desquama- 
tion. .  .  .  The  hps  and  buccal  ca\dty  are  h}-peremic, 
and  there  may  be  loss  of  surface  epitheHum  on  the  tongue. 
Palms  and  soles  are  hj^ermic,  due  to  dilated  arterioles, 
and  later  they  are  deeply  pigmented,  the  color  varying 
from  brown  to  intense  black.  The  gait  is  t^^^ically  ataxic. 
The  disease  attacks  both  sexes,  youths  and  adults,'-' 
(Marie.) 

For  quite  a  while  this  was  caUed  "Strachan's  disease," 


GENERAL  CONSIDERATIONS,  HISTORIC  AND  OTHERWISE   23 

but,  in  the  light  of  present  knowledge,  we  may  safely  class 
it  pellagra. 

Dr.  Patrick  Manson,  in  writing  on  "  beriberi "  (Tropical 
Diseases),  takes  issue,  and  in  a  foot-note  writes  as  fol- 
lows: "Dr.  Strachnan  has  described  a  form  of  multiple 
neuritis  which  he  calls  malaria.  The  disease  is  endemic, 
and  very  common  in  Jamaica.  It  differs  from  beriberi, 
inasmuch  as  it  is  not  attended  with  edema,  is  frequently 
attended  with  implication  of  the  cranial  nerves,  and  is 
rarely  fatal.  We  have  no  account  of  any  similar  disease 
of  other  tropical  countries.     .     .     ." 

Dr.  G.  L.  Manning,  the  medical  superintendent  of  the 
lunatic  asylum  at  Barbadoes,  has  reported  similar  cases 
there,  and  thinks  the  trouble  contagious,  recommending 
the  isolation  of  all  patients. 

Dr.  D.  J.  Williams,  of  Kingston,  Jamaica,  writes,  "The 
existence  of  pellagra  was  recognized  here  about  twelve 
years  ago,  but  as  then  it  was  unknown  in  the  West  Indies, 
and  the  correctness  of  the  diagnosis  was  questioned,  and 
the  erythematous  condition  of  the  exposed  limbs  at- 
tributed to  sunburn. 

"Four  or  five  years  ago  the  disease  was  very  prevalent. 
.  .  .  With  generous  diet,  rest  in  bed  and  tonics,  the 
majority  improved  temporarily;  others  made  no  improve- 
ment, but  suffered  from  chronic  diarrhea,  progressive 
weakness  and  emaciation,  until  death  ended  the  scene." 

Mexico,  Brazil,  Uruguay,  and  the  Argentine  Republic 
have  had  their  share  of  pellagra,  though  from  some  of  these 
countries  the  reports  are  hazy  and  indefinite. 

A  graphic  account  concerning  conditions  dietetic  and 
pellagrous  in  Yucatan,  Mexico,  has  been  furnished  by  Dr. 


24  PELLAGRA 

G.  F.  Gaumer  of  Izamal.  He  writes,  "  In  1882,  in  Yuca- 
tan, locusts  destroyed  vegetation,  especially  Indian  com. 
Corn  being  the  only  cereal  used  in  Yucatan  for  bread, 
famine  seemed  inevitable,  until  the  merchants  began  to 
import  it  from  New  York.  This  importation  continued 
till  1 89 1,  when  the  country  had  recovered  from  the  de- 
vastation of  the  locusts.  The  imported  corn  was  brought 
in  the  holds  of  vessels  £ls  ballast.  By  reason  of  exposure 
to  heat  and  humidity  on  the  voyage,  the  corn  underwent 
fermentation  and  became  unfit  for  food.  The  constant 
eating  of  this  spoiled  com  led  to  the  slow  development  of 
pellagra. 

"The  disease  was  confined  to  the  lower  and  middle 
classes,  who  were  obliged  to  purchase  the  cheapest  com  in 
the  market.  The  wealthy  classes  escaped,  as  they  did  not 
eat  the  imported  corn.  For  the  next  ten  years,  1891  to 
1 90 1,  Yucatan  produced  enough  com  for  home  consump- 
tion, and  cases  of  pellagra  no  longer  developed.  The 
old  cases  ran  their  course  fatally.  From  1901  to  1907  the 
corn  crops  were  almost  total  failures,  and  corn  was  again 
imported  in  larger  amounts  than  ever  before.  Mobile 
and  New  Orleans  were  the  chief  sources  of  supply,  but  some 
came  from  Vera  Cruz — all  by  water.  Again  pellagra  be- 
came epidemic,  but  was  not  confined  to  the  middle  and 
lower  classes  as  before.  It  had  been  found  more  profitable 
to  raise  hemp  than  corn,  so  all  classes  used  the  imported 
cereal.  Consequently,  pellagra  spread  alike  among  the 
rich  and  poor.  At  the  close  of  1907,  10  per  cent,  of  the 
inhabitants  were  the  victims  of  pellagra,  and  in  August, 
1909,  not  less  than  8  per  cent,  of  the  population  had  the 
disease." 


Egyptian  case  of  pellagra.     Note  the  "breast-plate"  on  exposed  surface 

of  breast. 


African  case  of  pellagra,  showing  erythema  on  back  of  neck,  and  shoulders. 


CHAPTER  II 
PELLAGRA  IN  THE  UNITED   STATES 

As  early  as  1863  two  cases  were  recognized  in  New  York 
and  Massachusetts — one  by  Dr.  John  P.  Gray,  of  Utica, 
New  York,  and  one  by  Dr.  Tyler,  of  Somerville,  Mass. 
It  might  not  be  amiss  to  mention  that,  at  this  time,  there 
were  reports  of  a  supposed  epidemic  of  pellagra  near 
Halifax,  Nova  Scotia,  though  details  were  lacking  and  the 
diagnosis  was  only  inferential. 

We  now  come  to  the  discussion  of  certain  conditions  in 
some  of  the  large  detention  camps  or  prisons  during  the 
late  Civil  War.  More  particularly,  may  we  revert  to 
Libby  Prison,  at  Richmond,  Va.,  and  the  Anderson ville 
prison,  both  used  for  Federal  prisoners,  though  the  for- 
mer was  mainly  for  officers,  and  the  latter  for  private 
soldiers. 

The  war  was  dragging  its  weary  length,  both  sides 
were  embittered  by  the  internecine  strife,  and  both  had 
severely  taxed  their  resources  to  carry  on  the  conflict. 

Far  be  it  from  the  writer  to  enter  into  any  discussion 
of  any  issues  involved,  or  the  wisdom  or  unwisdom  of  meas- 
ures employed  in  the  management  of  these  prisons. 

It  is  well  known  that  the  mortality  was  frightful. 

Right  at  that  time  the  South  was  staggering  in  the 
struggle  for  governmental  existence;  all  sustaining  indus- 

25 


26  PELLAGRA 

tries  were  paralyzed,  and  it  was  a  problem  to  find  suffi- 
cient sustenance  for  her  own  soldiery  and  people,  with  the 
added  burden  of  pro\dding  for  all  these  prisoners.  Corn 
was  the  principal,  sometimes  the  only  available,  food  to 
be  had,  and  the  facilities  for  transporting  and  preserving 
it  were  far  from  ideal. 

The  writer  has  been  able  to  interview  several  veterans  of 
intelligence,  who  were  at  Andersonville  during  that  dread- 
ful period — two  who  were  guards  and  one  who  was  a 
prisoner — and  the  details,  even  softened  by  all  the  years  of 
healing  time,  were  harrowing  in  the  extreme. 

The  hygienic  facilities  were  primitive,  nor  was  much 
effort  made  to  enforce  those  supposed  to  be  in  vogue.  A 
major  part  of  the  diet  was  of  corn  products,  some  of  which 
had  been  through  more  than  one  wetting  and  drying,  and 
which  were  mouldy  or  wormy.  The  water  was  bad,  the 
surroundings  were  depressing,  and  these  poor  men  suf- 
fered the  pangs  of  illness,  to  which  were  added  the  sorrows 
of  nostalgia — that  dread  of  wanderers  far  from  home. 

Little  wonder  it  was  that  they  sickened  and  died,  and 
fortunate  the  few  who,  "  by  reason  of  strength,"  were 
able  to  withstand  the  noisome  odors,  the  scanty  and  un- 
wholesome food,  and  the  depressing  influences  on  every 
side. 

Dr.  J.  W.  Kerr,  of  Corsicana,  Texas,  has  -wTitten  a 
report  of  some  of  the  conditions,  and,  in  the  Ught  of  a 
clearer  retrospective  vision,  he  beHeves  that  pellagra  was 
the  evil  agent  responsible  for  many  deaths. 

The  veterans  mentioned  above  have  told  the  writer 
how  the  men  had  a  supposed  eczema;  how  they  loathed 
their  food,  and  how  it  served  them  after  it  was  eaten;  how 


PELLAGRA  IN  THE  UNITED   STATES  27 

their  skins  were  rough  and  hard,  and  how  their  hands  were 
sore  and  cracked;  how  their  bowels  were  chronically  loose 
— so  much  that  there  was  a  pathetic  joke  that  a  prize  would 
be  given  any  prisoner  having  a  solid  fecal  movement. 
Upon  this  weight  was  superimposed  the  melancholy 
deepening  into  the  different  forms  of  dementia,  where 
indifference  to  fate  brought  about  increased  carelessness 
as  to  common  rights  in  their  adversity,  or  hygienic  pre- 
cautions that  would  have  ameliorated  the  common  lot. 

Whether  or  not  this  was  really  pellagra  will  probably 
not  be  positively  known,  but  there  is  a  widespread  belief 
among  students  of  history  that  such  was  the  disease  which 
brought  to  an  untimely  end  many  of  the  flower  of  the 
Federal  army. 

From  1864  up  to  1883  we  hear  nothing  more  of  this 
disease,  when  one  case  was  reported  by  Dr.  S.  Sherwell, 
of  Brooklyn,  New  York,  in  a  Genoese  sailor. 

Dr.  H.  N.  Sloan  asserts  that  pellagra  was  diagnosed  in 
the  South  Carolina  Asylum  at  Columbia  in  the  early 
'70s,  but  no  written  nor  printed  record  has  been  found. 
Dr.  D.  S.  Pope,  of  Columbia,  as  quoted  by  Dr.  Babcock, 
is  satisfied  that  at  least  two  cases  occurred  in  the  South 
Carolina  penitentiary  in  the  middle  '80s. 

In  1889,  Dr.  Bemis,  of  New  Orleans,  left  a  written 
diagnosis  of  a  case  in  a  white  woman  at  the  Charity  Hospi- 
tal in  that  city. 

During  all  these  years  it  is  practically  certain  that 
pellagra  existed  plentifully  in  the  Southern  States  under 
various  diagnoses.  Such  puzzling  cases  were  diagnosed 
as  unusual  manifestations  of  tuberculosis,  syphilis,  malaria, 
acute   delirium,    dementia,    melancholia,    hook-worm,    ec- 


28  PELLAGRA 

zema,  dermatitis  exfoliativa,  and  others.  In  some  quar- 
ters, somewhat  removed  from  the  medical  centers,  where 
the  niceties  of  diagnosis  were  hardly  appreciated,  some  of 
the  appellations  applied  to  undoubted  cases  of  pellagra 
would  have  been  humorous,  had  they  not  been  fraught 
with  dangerous  consequences  for  the  sufferers.  "  Ele- 
phant itch,"  "  seven-years  itch,"  "  country  scurvy," 
"  poison  oak  or  ivy,"  but,  most  of  all,  eczema,  that  medi- 
cal mantle  that  covers  so  many  slipshod  diagnoses. 

The  writer  well  remembers  a  case  occurring  in  a  mulatto 
girl  twenty- two  years  ago,  the  manifestations  of  which  he 
was  unable  to  understand  at  the  time,  but  which  seem 
plain  in  the  Hght  of  present  knowledge. 

This  girl,  an  intelligent  school  teacher,  twenty  years  of 
age,  was  treated  for  diarrhea,  indigestion,  and  nervous- 
ness during  the  months  of  March,  April,  and  May.  Her 
diarrhea  and  indigestion  improved,  but  she  remained  ner- 
vous and  averse  to  work  all  the  summer.  That  faU  and 
winter  she  seemed  well,  but  in  the  following  March  her 
diarrhea  returned  worse  than  before,  with  the  other  at- 
tendant symptoms  magnified.  She  also  had  an  "  ecze- 
matous  "  eruption  on  her  hands  and  feet,  symmetric  and 
sunburned  in  appearance.  She  was  much  depressed 
mentally,  so  that  she  gave  up  her  school,  and  changed 
her  home,  with  the  hope  that  new  environments  would 
help  both  her  digestion  and  mental  condition.  She  seemed 
to  improve,  and,  by  November,  she  returned,  apparently 
well,  though  reduced  in  weight. 

The  following  March  showed  a  renewal  of  every  symp- 
tom in  aggravated  form,  wdth  rapid  emaciation,  frequent 
involuntary  stools,  hands  and  feet  first  erythematous,  then 


PELLAGRA  IN  THE  UNITED  STATES  29 

raw  and  weeping,  a  settled  melancholy,  and  death  in  the 
early  part  of  May. 

This  patient  was  seen  by  some  well-posted  physicians, 
but  none  of  them  were  able  to  make  a  diagnosis. 

In  1900,  the  writer  saw  two  fatal  cases  of  this  sort — 
one  in  his  own  practice  and  the  other  with  a  confrere — 
both  of  whom  gave  a  history  of  recrudescences  and  ex- 
acerbations through  several  preceding  years. 

All  of  these  patients  were  in  agricultural  districts,  were 
in  limited  circumstances,  and  had  always  eaten  corn-meal. 

With  the  slight  exceptions  mentioned,  the  pellagra  situa- 
tion remained  in  statu  quo  until  1902,  when  Dr.  H.  F. 
Harris,  of  Georgia,  reported  a  case. 

As  has  so  frequently  happened  to  the  prophecy  of  a 
prophet  in  his  own  country,  the  report  of  Dr.  Harris  ex- 
cited but  little  comment,  and  practically  nothing  more 
was  heard  of  pellagra  until  about  1907,  when  independent 
reports  from  various  sections  of  the  South  began  to  come 
in.  Medical  officers  of  asylums  in  South  Carolina  and  Ala- 
bama reported  such  cases  with  scientific  exactness,  and  in 
the  summer  of  1908  Drs.  Babcock  and  Watson,  of  Colum- 
bia, S.  C,  went  to  Italy  to  study  the  disease. 

On  their  return,  they  were  able  to  positively  identify  it, 
and,  as  they  wrote  of  it,  others  began  to  remember  cases 
in  practice  of  past  years;  cases  not  diagnosed;  cases  whose 
deaths  were  hard  to  explain. 

In  rapid  succession,  pellagra  was  then  reported  from 
Wilmington,  Morganton,  and  Charlotte,  N.  C;  Augusta, 
Milledgeville,  and  Atlanta,  Ga.;  Tuscaloosa  and  Mont- 
gomery, Ala.;  Colmnbia  and  Charleston,  S.  C;  and  many 
other  places  in  a  number  of  states. 


30  PELLAGRA 

In  1909,  the  people  of  the  South,  as  well  as  the  officials 
of  the  Public  Health  and  ^Marine  Hospital  Service,  who 
had  already  made  valuable  investigations,  began  to  wake 
up  to  the  gravity  of  the  situation,  and  in  November,  1909, 
a  Conference  on  Pellagra  was  held  under  the  auspices  of 
the  South  Carolina  State  Board  of  Health  at  the  State 
Hospital  for  the  Insane,  Columbia,  S.  C.  Another  Con- 
ference on  Pellagra  was  held  at  the  same  place  in  October, 
1912,  which  assumed  a  national  importance. 

At  these  conferences  representative  men,  physicians, 
pubHcists,  students  of  sociologic  problems,  and  citizens  of 
every  walk  of  life  attested  their  interest  by  their  presence. 

The  discussions  and  deUberations  as  to  the  etiology, 
pathology,  and  clinical  aspects  of  this  disease  will  receive 
attention;  suffice  it  to  say,  that  the  ear  of  the  American 
people  was  reached,  and  pellagra,  as  an  American  problem, 
was  driven  home  to  the  most  skeptical. 

Since  that  time,  up  to  the  present  writing,  the  question 
has  been  not  one  of  fact,  but  of  degree.  At  that  time 
about  I0CX5  cases  had  been  reported  from  thirteen  states, 
but,  as  the  returns  have  come  in,  practically  every  state  in 
the  Union  reports  within  its  borders  either  positive  or  sus- 
pected cases. 

In  some  of  the  states  the  existence  of  pellagra  has  received 
much  more  than  passing  notice,  as  attested  by  many  and 
valuable  contributions  as  to  its  features  as  it  has  appeared 
in  different  localities. 

Dr.  J.  N.  Hewett,  of  Ljomhaven,  Va.,  and  Dr.  Beverly 
Tucker,  of  Richmond,  have  studied  many  non-institutional 
cases  in  their  and  adjoining  states,  being  convinced  that  it 
exists  to  a  far  greater  extent  than  is  commonly  realized. 


PELLAGRA  IN  THE  UNITED   STATES  3 1 

In  only  a  very  few  states  is  the  occurrence  of  the  disease 
required  to  be  reported,  and  in  the  absence  of  records  of 
cases  it  is  quite  impossible  to  know  how  much  of  the 
malady  exists;  and  that  of  the  states  in  which  the  disease 
is  notifiable  the  only  one  which  is  really  getting  reports  is 
the  state  of  Mississippi,  where  the  number  of  cases  reported 
during  the  last  three  months  of  19 14  were  as  follows: 

October,  1914 824  cases. 

November,  1914 603  cases. 

December,  1914 418  cases. 

Among  the  states  where  pellagra  has  assumed  formidable 
proportions  are  Virginia,  North  and  South  Carolina, 
Georgia,  Florida,  Alabama,  Mississippi,  Louisiana,  Texas, 
Tennessee,  Illinois,  Missouri,  Kentucky,  and  Arkansas. 
In  others,  the  health  officers  are  on  the  watch  for  sporadic 
cases,  but  do  not  seem  to  locate  very  many. 

That  some  of  these  returns  are  incomplete  is  in  many  in- 
stances shown  on  their  faces.  For  instance,  Florida  re- 
ported only  50  cases  up  to  191 1  in  the  whole  state.  The 
writer  alone  had,  in  that  year,  seen  18  cases  from  that 
state  that  came  to  this  city  from  Florida  for  treatment.  If 
that  many  came  to  one  city  for  treatment,  the  inference  is 
plain  that  there  must  have  been  many  more  than  32  who 
remained  at  home. 

Again,  there  is  a  sentiment  springing  up  in  some  quar- 
ters that  pellagra  is  a  "  loathsome  disease,"  and  one  in 
which  the  afflicted  pellagrin  does  not  wish  the  public  to 
know  its  presence. 

A  short  time  ago  the  writer  treated  a  widow  lady,  who, 
when  she  was  informed  that  her  trouble  was  pellagrous, 


32  PELLAGRA 

earnestly  requested  that  her  son  be  not  informed  what 
was  the  matter.  She  seemed  to  feel  ashamed  of  her  ail- 
ment, nor  could  she  be  reassured  by  any  persuasive  arts 
of  her  medical  attendant. 

A  lady  from  Florida  recently  was  in  Atlanta  for  treat- 
ment, and,  upon  the  rumor  that  she  had  pellagra  becoming 
rife  in  the  -family  hotel  where  she  boarded,  some  of  the 
boarders  rose  in  arms,  insisting  that  if  the  proprietress 
did  not  ask  her  to  leave,  they  would  seek  other  homes. 
She  was  asked  to  leave,  and  did  so. 

Many  of  the  public  hospitals  and  sanatoria  have  passed 
rules  excluding  pellagrins,  and  can  it  be  wondered  that 
these  unfortunate  invahds  use  every  effort  to  keep  from 
general  knowledge  the  real  nature  of  their  malady? 

In  more  than  a  few  instances  the  statement  to  an  in- 
quiring patient  that  pellagra  was  the  diagnosis  has  brought 
forth  expressions  of  either  incredulity  or  indignation,  fol- 
lowed by  impassioned  appeals  that  no  one  be  informed  of 
the  nature  of  the  illness. 

Many  times  the  patient, .  with  an  assumed  skepticism, 
goes  to  the  family  physician,  carrying  the  plainly-impKed 
desire  that  the  diagnosis  be  not  verified.  The  physician, 
being  anxious  to  give  his  troubled  questioner  the  benefit 
of  every  doubt,  admits  that  perhaps  there  is  a  mistake, 
and,  upon  this  figment  of  imcertainty,  the  patient  boldly 
asserts  that  a  mistake  has  been  made,  that  only  an  "  ec- 
zema "  causes  the  eruption,  that  some  dietetic  errors  are 
responsible  for  the  gastro-intestinal  manifestations,  and 
that  something  else  is  behind  the  nervousness. 

To  place  this  patient  in  the  pellagra  column  would,  if 
known,  excite  a  stormy  protest. 


PELLAGRA  IN  THE  UNITED  STATES  33 

This  picture  will  bring  to  many  readers  the  memory 
of  just  such  a  state  of  affairs,  and  can  we  wonder  that 
reliable  statistics  are  hard  to  obtain  ? 

The  writer,  from  exhaustive  inquiry  among  health 
officers,  asylum  superintendents,  and  other  interested 
observers,  believes  that  a  present  estimate  of  forty  thousand 
pellagrins  in  the  United  States  is  not  far  from  correct. 

"Like  appendicitis,  the  disease  is  now  better  diagnosed — 
hence  the  seeming  rapid  increase;  although,  for  some  un- 
known reason,  there  is  probably  a  real  increase,  but  not  so 
great  as  it  appears."     (Babcock.) 

It  would  be  puerile  for  any  of  our  states,  no  matter  how 
far  north,  with  a  "holier  than  thou"  attitude,  to  dis- 
claim its  presence,  or  to  minimize  the  reality  of  the  prob- 
lem now  at  our  doors. 

Not  so  many  years  ago  the  late  Grover  Cleveland  ut- 
tered that  epigram,  "  A  condition  and  not  a  theory  con- 
fronts us,"  and  well  may  we  apply  those  words  to  the 
visitation  of  this  malady  that,  unless  checked,  will  bring 
sorrow  to  many  hearthstones  and  disquietude  to  many 
municipaUties  and  states. 
3 


CHAPTER  III 
A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA 

It  is  with  a  sense  of  trepidation  that  the  writer  enters 
into  the  discussion  of  the  etiology  of  this  disease.  That 
spoiled  maize  was  an  etiologic  factor  was  suspected  by 
Casal,  who,  in  1762,  attempted  to  elucidate  the  causal 
relationship  between  the  com  and  the  "  mal  de  rosa," 
as  he  dubbed  it. 

This  suspicion  remained  somewhat  quiescent,  though  not 
entirely  absent,  until  Mazari  formulated  a  theory  that  the 
disease  was  brought  about  by  the  lack  of  certain  nutritious 
quaHties  in  corn. 

About  this  time,  two  schools  of  thought  arose,  the  one 
espousing  the  "  Zeist  "  theory  (from  Triticum  spelta,  or 
Zea  Mays),  the  other  opposing  it. 

For  many  years  a  spirited,  sometimes  acrimonious, 
battle  raged  between  these  two  schools,  the  echoes  rising 
and  falling  like  the  swell  of  an  ocean,  as  greater  or  lesser 
minds  engaged  in  the  wordy  conflict. 

Had  this  chapter  been  written  in  1912  or  19 13  the  writer 
would  have  hesitated  in  devoting  much  space  to  the  "Zeist" 
theory.  At  present,  however,  the  trend  of  opinion  is  de- 
parting from  the  belief  that  pellagra  is  transmitted  by  a 
winged,  blood-sucking  insect,  and  is  leaning  more  toward 
the  idea  of  its  etiolog>'  b^hig  in  an  unbalanced  diet  con- 
34 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       35 

taining  an  excessive  proportion  of  corn  or  corn  products, 
with  other  cereals  and  vegetables. 

For  this  reason  it  is  still  of  interest  to  study  the  early- 
history  of  maize,  its  distribution,  and  food  consumption. 
The  chemistry  of  spoiled  and  sound  corn  also  will  be  con- 
sidered. 

Maize  is  a  plant  of  the  tribe  Maydeae,  of  the  order 
Gramineae  or  grasses.  It  is  unknown  in  the  native  state, 
but  is  probably  indigenous  to  tropical  America.  Small 
grains  of  an  unknown  variety  have  been  found  in  the 
ancient  tombs  of  Peru,  and  Darwin  found  heads  of  maize 
embedded  on  the  shore  of  Peru  at  85  feet  above  the  pres- 
ent sea  level. 

Bonafous,  however  {Histoire  naturelle  du  mats),  quotes 
authorities  as  believing  that  it  originally  came  from  Asia, 
and  maize  was  said  by  Santa  Rosa  de  Viterbo  to  have 
been  brought  by  the  Arabs  into  Spain  in  the  thirteenth 
century.  A  drawing  of  maize  is  also  given  by  Bonafous, 
from  a  Chinese  work  on  natural  history,  dated  1562,  a 
little  over  sixty  years  after  the  discovery  of  the  New  World. 
It  is  not  figured  on  Egyptian  monuments,  nor  was  any 
mention  made  of  it  by  Eastern  travelers  in  Africa  or  Asia 
prior  to  the  sixteenth  century. 

Humboldt,  Alphonse  de  Candolle,  and  others,  however, 
do  not  hesitate  to  assert  that  it  originated  solely  in  America, 
where  it  had  been  long  and  extensively  cultivated  at  the 
period  of  the  discovery  of  the  New  World,  and  that  is  the 
generally  accepted  modern  view. 

Passing  the  purely  botanical  aspect  of  the  stalk  and 
outer  covering  of  the  grain,  or  husk,  which  does  not  con- 
cern us  here,  we  find  that  Indian  corn  is  a  very  nutritious 


36  PELLAGRA 

article  of  food,  being  richer  in  albuminoids  than  any  other 
cereals  when  ripe  (calculated  in  the  dry  weight).  It  can 
be  grown  in  the  tropics,  from  the  level  of  the  sea  to  a  height 
equal  to  that  of  the  Pyrenees,  and  in  the  south  ajid  mid- 
dle of  Europe,  but  cannot  be  grown  profitably  in  England. 
It  is  extensively  grown  throughout  India,  and  is  the  most 
common  crop  throughout  South  Africa,  where  it  is  known 
as  mealies,  being  the  staple  food  of  the  natives. 

As  an  article  of  food,  maize  is  one  of  the  most  extensively- 
used  grains  in  the  world.  It  contains  more  oil,  too,  than 
any  other  cereal,  ranging  from  3.5  to  9.5  per  cent,  in  the 
dried  commercial  grain. 

Sound,  matured,  and  well-dried  com  is  one  of  the  most 
available,  as  well  as  most  nutritious,  of  the  foods  offered 
the  human  race.  Under  proper  methods  of  transportation 
it  can  be  hauled  an  indefinite  distance  without  deteriora- 
tion; and,  when  properly  gathered  and  marketed,  it  will 
remain  sound  and  wholesome  for  years. 

On  the  other  hand,  no  grain  is  more  susceptible  to  un- 
sanitary influences  or  careless  handling. 

That  the  eating  of  spoiled  corn  has  made  a  decided  im- 
press on  the  language  of  the  Italians  may  be  judged  by  the 
names  given  in  different  dialects  to  express  its  odor — scagn, 
muffito,  pati,  sobbolli,  verdet,  butta,  arbolli,  smaserido,  romat- 
ico,  mofflet,  etc. 

On  gross  examination  by  the  ordinary  observer,  spoiled 
corn  may  be  distinguished  by  its  cracked  or  wrinkled  hull, 
its  color  of  old  gold,  its  lack-luster  appearance  with  embryo 
enlarged,  blackish,  and  showing  through  the  surface  like  a 
ship  in  a  fog.  It  nearly  always  shows  external  spots  of  a 
brownish  or  greenish  color  Hke  verdigris. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       37 

If  the  grain  is  cut  in  half  and  examined,  the  perisperm 
shows  brownish,  and  the  embryo  a  dingy  black,  instead 
of  the  white  of  good  grain.  The  mass  of  the  perisperm  is 
often  eaten  away,  leaving  a  little  cavity  in  which  is  found  the 
"coleoptera  nesting  there,  and  a  fine  dust  can  be  shaken  out 
of  the  grain.  These  coleoptera  are  called  "  corn  weevils  " 
by  the  laity,  and  corn  so  affected  is  considered  unfit  for 
human  food. 

The  embryo  is  nearly  always  atrophied,  so  that  it  does 
not  fill  out  its  normal  place  between  the  perisperm  and  the 
hull  of  the  caryopsis.  Sometimes  the  outward  appear- 
ance of  the  grains  seems  normal,  but  there  can  be  noticed, 
on  close  inspection,  little  eroded  points  scattered  over  the 
surface,  favoring  the  development  of  some  of  the  moulds. 
From  this  also  comes  a  greenish  dust,  which  seems  to 
penetrate  the  interior  of  the  grain.  In  many  grains  the 
appearance  of  the  moulds  and  the  acarus  farina  coincide. 

The  meal  made  from  spoiled  corn  is  not  always  easy 
to  detect,  unless  it  is  decidedly  bad.  When  much  dam- 
aged, it  gives  off  a  "  musty  odor,"  sometimes  slightly 
aromatic,  and  has  a  bitter  taste. 

Several  tests  for  spoiled  corn  are  mentioned  by  Marie, 
which  are  said  to  be  fairly  conclusive.  He  says,  if  some 
grains  of  spoiled  corn  are  digested  in  90  per  cent,  alcohol, 
their  grayish-yellow  color  changes  to  an  intense  red,  the 
alcohol  becomes  red,  and  the  color  deepens  with  time. 
On  the  contrary,  if  the  grain  is  sound,  it  does  not  change 
color,  even  if  it  remains  in  the  alcohol  for  two  months, 
though  the  alcohol  becomes  yellow. 

Again,  if  in  a  dilute  solution  of  caustic  potash  the  hull 
of  the  grain  of  spoiled  corn  becomes  first  reddish  brown, 


38  PELLAGRA 

later  all  the  solution  becomes  brown,  and  gives  off  a  pene- 
trating odor  of  spoiled  corn.  The  more  the  decomposi- 
tion of  the  corn  has  advanced,  the  more  decided  is  the 
reaction.  If  this  alkahne  fluid  is  neutralized  by  tartaric 
acid,  flakes  of  a  coffee  color  are  precipitated  which  have 
the  odor  of  spoiled  corn;  these  flakes  are  insoluble  in 
water  or  ether,  but  soluble  in  alcohol.  This  reaction, 
according  to  Marie,  can  be  obtained  with  both  meal  and 
bread  made  of  spoiled  corn,  the  reaction  showing  a  lemon- 
yellow  color. 

Following  the  experiments  of  this  investigator,  we  find 
that  the  tincture  of  spoiled  corn  3delds  three  substances. 
The  first  is,  at  ordinary  temperature,  a  liquid  of  ruby  red 
color,  with  a  bitter  taste,  and  an  odor  of  decayed  corn. 
It  is  soluble  in  alcohol  and  ether,  but  insoluble  in  water, 
in  which  it  floats ;  it  becomes  resinous  when  exposed  to  air, 
and  does  not  yield  a  precipitate  with  the  iodid  of  potash, 
nor  with  other  metallic  salts.  With  caustic  potash  and 
benzin  it  yields  a  bright  yellow  precipitate,  and  a  drop 
of  it  on  paper  makes  a  greasy  spot.  This  tincture  contains 
the  oily  substance  of  corn,  and  may  be  called  the  red  oil 
of  spoiled  corn. 

The  second  substance  is  a  reddish  brown,  styptic  and 
bitter,  is  soluble  in  ordinary  alcohol,  but  in  absolute  alcohol 
it  precipitates  yellowish  flakes,  which  dissolve  quickly 
if  a  little  distilled  water  is  added.  It  is  also  insoluble  in 
ether,  and  yields,  when  treated  with  iodid  of  potassium,  a 
flaky  precipitate;  with  sulphate  of  copper  it  becomes  green; 
if  treated  with  much  water,  it  separates  into  two  parts,  one 
of  which,  insoluble,  is  precipitated  in  the  form  of  a  brown 
amorphous   powder;    the   other   makes   a   bright   yellow 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       39 

solution.  This  interesting  product  is  called  pellagrocein, 
or  the  toxic  substance  of  spoiled  corn,  and  its  toxic  proper- 
ties are  very  marked. 

The  third  substance,  when  heated  with  ether,  solidifies 
into  a  mass,  which  becomes  hard  on  exposure  to  the  air. 
It  is  soluble  in  diluted  alcohol  and  in  a  solution  of  caustic 
potash,  but  in  water,  benzin,  or  absolute  alcohol  it  is 
insoluble.  When  heated  it  becomes  soft,  and  can  be 
drawn  out  like  wax.  This  is  the  resinous  substance  of 
spoiled  corn. 

It  may  be  interesting  to  note  that  the  substances  ob- 
tained from  spoiled  corn  are  analogous  to  those  obtained 
from  spurred  rye,  possessing  the  same  oxytocic  properties. 

A  great  number  of  micro-organisms  have  been  found 
in  spoiled  corn  by  investigators  on  "  both  sides  of  the 
water,"  and  it  would  not  be  profitable  to  enter  into  a  de- 
scription of  them  all,  but  the  more  important  will  be 
considered. 

Sporisorium  Maidis. — This  is  the  best-known  parasite 
of  spoiled  corn.  Its  isolation  and  description  inaugurated 
a  new  era  in  the  study  of  pellagra  in  Italy.  Seen  under 
the  microscope,  it  is  of  a  greenish  color,  resembling  little 
globules,  but  not  coherent. 

Balardini,  who  first  isolated  and  experimented  with 
this  micro-organism,  found  that  when  eaten  for  a  while 
by  man,  it  would  produce  gastritis  and  diarrhea. 

It  has  been  common  knowledge  among  the  laity  for 
many  years  that  "  musty  meal,"  or  spoiled  corn,  would 
cause  illness  in  man  or  beast;  and  the  writer  remembers 
how,  when  a  lad,  his  mother  lost  many  fine  chickens  from 
a  mysterious  malady,  which  was  solved  when  the  cook 


40  PELLAGRA 

was  discovered  to  have  been  feeding  the  fowls  on  dough 
made  from  spoiled  meal. 

Lombroso  did  not  think  this  organism  responsible  for 
pellagra,  however,  because  he  could  not  find  it  often  in 
Lombardy,  but  others  have  thought  differently. 

Probably  the  most  important  fungus  is  the  penicillium 
glaucum,  which,  while  it  forms  on  other  grains  besides 
com,  does  not  in  them  seem  to  produce  the  pellagra  poison, 
and  is  not  of  itself  toxic  to  the  human  system. 

It  is  observed  in  pendicular  filaments,  from  which 
are  developed  many  flaky  conidia.  These  filaments  com- 
pose the  greenish-blue  dust,  which  is  often  noticed  on  the 
grains  of  spoiled  com.  It  does  not  long  remain  on  the 
surface,  but,  when  the  corn  is  not  housed  in  dry  quarters, 
seems  to  penetrate  into  it. 

Says  Lombroso,  "  Pellagra  does  not  come  directly  from 
the  penicillium,  but  from  the  pellagrozeina  (identical  with 
strychnin),  formed  in  the  com  as  a  result  of  the  action  of 
the  penicillium. 

Other  micro-organisms  of  probably  less  importance  are 
the  oidium  lactis  maidis,  eurotium  herbariorum,  sporothri- 
cum  maidis,  bacterium  maidis,  and  the  aspergillus  glaucus, 
the  last  of  which  is  found  in  the  same  conditions  as  the 
penicillium,  but  more  rarely. 

The  bacterium  maidis  has  not  been  found  alone  in 
faulty  meal,  but  has  also  been  found  in  sound,  and  in  the 
bread  made  from  such  meal. 

"  In  1881  Majocchi  found  a  very  motile  bacteriima  in 
both  sound  and  spoiled  corn,  but  always  in  greater  num- 
ber on  spoiled  corn — this  micro-organism  he  called  bac- 
terium maidis,  and  he  thought  he  found  it  in  the  blood 


''  A  Lombroso  chicken."     This  fowl  was  fed  for  four  weeks  on  spoiled 
meal.     (Courtesy  of  Dr.  H.  P.  Cole,  Mobile,  Ala.) 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       41 

of  seven  pellagrins  in  the  first  stage  of  the  disease.  Cu- 
boni,  working  with  this  micro-organism,  found  it  con- 
stantly and  abundantly  on  spoiled  corn.  He  also  called 
it  bacterium  maidis,  and  recognized  its  similarity  to  the 
bacterium  termo,  though  it  resisted  a  higher  tempera- 
ture."    (Marie.) 

According  to  most  observers,  this  bacterium  occurs 
more  readily  in  damp  or  immature  corn,  its  develop- 
ment being  arrested  by  dr3dng,  though  on  each  fresh  wet- 
ting of  the  grain  it  can  renew  its  development.  This 
explains  why  corn  can  be  partly  "  sweetened,"  and  then, 
on  exposure  to  dampness  or  other  unfavorable  circum- 
stances, can  again  become  unfit  for  food. 

Cuboni  thought  that  the  intestines  of  pellagrins  offered 
an  exceptionally  favorable  soil  for  the  propagation  of 
these  bacteria,  while  they  did  not  thrive  so  well  in  the 
intestines  of  healthy  individuals. 

Paltauf  and  Heider  have  concluded  from  their  studies 
that  the  bacterium  maidis  is  the  original  potato  bacillus, 
transplanted  to  a  new  soil  and  christened  with  a  new 
name.     They  are  not  alone  in  this  view. 

As  in  other  grains  where  there  is  a  large  percentage 
of  starch,  the  saccharomycetes  are  numerous  in  spoiled 
corn,  but  fermentative  processes  are  necessarily  due 
to  other  causes,  and  may,  to  an  extent,  be  ascribed  to  the 
bacterium  termo. 

Much  study  has  been  given  to  the  different  moulds 
on  spoiled  com,  but  not  many  observers  in  America  have 
followed  it  up.  To  our  painstaking  friends,  the  ItaHans, 
we  owe  most  of  our  information  on  this  subject,  though 
the  French  have  not  lagged  far  behind. 


42  PELLAGRA 

Monti  and  Tirelli,  using  the  methods  of  Koch,  have 
made  some  very  interesting  studies  of  this  subject.  They 
found  fourteen  different  organisms,  some  of  which  have 
already  been  specified  (one  of  them  the  potato  bacillus 
under  its  own  name),  and  they  opine  that  none  of  these 
are  capable  of  directly  injuring  the  human  organism, 
but  all  are  capable  of  inaugurating  decomposition  in  differ- 
ent cereals.  None  of  these  organisms  flourish  when  the 
grain  is  kept  dry,  but  require  a  certain  amount  of  moist- 
ure, and,  in  some  instances,  a  variable  degree  of  heat,  in 
order  that  they  may  develop. 

The  peniciilium  glaucum  will  flourish  at  a  lower  tem- 
perature than  most  of  the  others,  and  consequently  it  is 
more  often  present.  For  this  reason  it  has  possibly  re- 
ceived undue  importance. 

Many  experiments  have  been  made  with  the  bacterium 
maidis  by  Lombroso  and  others.  Into  white  mice  the 
alcoholic  extract  of  corn-meal,  infected  with  the  bacillus, 
was  injected.  Doses  of  0.5  c.c.  were  injected,  producing 
coma,  paralysis,  and  death  at  the  end  of  about  two  hours. 

Here  are  some  other  experiments  made  by  Lombroso 
and  his  contemporaries,  as  narrated  by  Marie: 

If  cultures  on  polenta  of  one,  two,  six,  and  up  to  seven, 
days  old  are  given  to  animals  they  become  accustomed  to 
it  slowly;  the  initial  diarrhea,  which  is  the  only  symptom, 
may  even  cease;  but  cultures  over  four  to  five  days  old  are 
refused,  perhaps  because  of  their  bad  and  very  pronounced 
taste.  As  a  consequence  of  this  nourishment,  digestive 
troubles  are  produced,  sometimes  vomiting,  almost  al- 
ways diarrhea,  but  never  derangement  of  the  sensibilities 
or  of  the  motor  system.     At  the  end  of  some  days  the 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       43 

weight  begins  to  diminish,  but  then  maintains  itself  within 
normal  limits.  The  temperature  is  usually  maintained  at 
normal;  in  the  first  days  only  two  cases  showed  a  slight 
evening  rise. 

The  attempt  to  cultivate  this  bacillus  on  wheat  bread  met 
with  little  success;  two  pigs,  fed  for  fourteen  days  with 
this  bread,  showed  no  change. 

An  experiment  was  then  made  with  the  alcoholic  ex- 
tract obtained  from  a  culture  on  polenta  twenty-five  days 
old.  The  extract,  prepared  by  Prof.  Fileti,  was  injected 
into  three  dogs,  under  the  skin  of  the  back,  in  doses  of  5 
per  cent.,  10  per  cent.,  and  25  per  cent,  of  the  weight  of 
the  animal.  The  two  dogs  which  had  received  the  largest 
doses  died  two  days  later,  after  presenting  the  following 
symptoms : 

Paresis  of  the  hind  legs,  almost  continual  tremor,  gen- 
eral depression,  which  was  rapid  and  progressive,  gradual 
loss  of  voluntary  motion,  complete  paralysis  of  the  hind 
legs,  mydriasis,  slight  increase  of  temperature,  accelera- 
tion of  respiration  and  pulse,  insensibility,  bloody  diarrhea, 
and  death  with  prolonged  agonistic  state.  At  the  autopsy 
edema  of  a  hemorrhagic  nature  in  the  hypogastric  region 
and  the  extravasations  in  the  spleen. 

The  dog  inoculated  in  the  proportion  of  5  per  cent,  of 
its  weight  exhibited  at  the  beginning  the  same  symptoms, 
but,  at  the  end  of  the  second  day,  his  condition  improved; 
however,  the  hind  legs  remained  paralyzed,  and  the  diar- 
rhea continued  for  several  weeks  with  a  remarkable  dimi- 
nution of  weight. 

In  the  case  of  two  other  dogs,  intravenous  injections,  in 


44  PELLAGRA 

a  proportion  of  5  per  cent,  of  body  weight,  caused  death 
after  the  development  of  the  above-mentioned  symptoms. 

Injections  into  ten  frogs,  with  corresponding  doses, 
brought  on  death  in  three  hours  with  paralysis,  diffuse 
ecchymoses  on  the  interior  of  the  thighs  and  into  the 
hypogastric  region.  Intravenous  injections  of  the  extract 
of  sound  polenta  up  to  10  per  cent,  had  no  evil  conse- 
quences; the  same  may  be  said  of  the  subcutaneous  injec- 
tions made  in  double  doses. 

After  this  somewhat  lengthy  discussion  concerning  corn, 
spoiled  and  otherwise,  it  will  more  interest  the  reader  to 
plunge  "  in  medias  res,'''  and  give  in  more  intelligible  terms 
the  theoretic,  if  not  real,  connection  between  maize  and 
pellagra. 

Lombroso  has  been  the  high  priest  of  the  zeists,  his 
arguments  have  been  weighty  and  voluminous,  and  it  has 
required  a  stout  heart  and  a  nimble  wit  to  cope  with  him. 
Even  since  his  death  the  material  he  left  behind  has  proved 
the  bulwark  of  the  adherents  of  the  maize  theory  as  to  the 
causation  of  this  disease,  and  all  that  has  been  written  or 
said  has  necessarily  partaken  of  his  arguments. 

Dr.  C.  H.  Lavinder,  in  a  logical  and  fair  discussion  con- 
tributed to  the  New  York  Medical  Record,  traces  from  an 
early  period  the  doctrine  adduced  by  Balardini  as  to 
"  verderame  "  up  to  the  present,  and  the  writer  makes  ac- 
knowledgments for  the  use  of  these  statements. 

The  early  views  have  been  sufficiently  covered,  so  the 
status  of  to-day  may  be  given  as  follows: 

"I.  It  is  declared  that  history  and  observation  show 
clearly  that  the  first  appearance  of  peUagra,  and  its  later 
dissemination  followed,  more  or  less  closely,  the  introduction 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       45 

of  maize  culture  into  Spain  and  its  gradual  spread  to 
France,  Italy,  and  other  countries  of  southern  Europe. 

"II.  It  is  declared  that  pellagra  is  found  as  an  endemic 
disease  only  in  those  countries  where  maize  is  grown,  and 
extensively  used  as  an  article  of  diet  by  the  poorer  rural 
classes.  It  is  of  importance  to  note,  on  the  other  hand,  that 
the  area  in  which  pellagra  is  found  endemic  is  but  as  a 
spot  upon  the  extensive  area  over  which  the  maize  is  found 
under  cultivation.  There  are  vast  tracts  where  maize  is, 
and  has  been,  grown  as  food  for  many  years,  and  yet 
no  pellagra  has  appeared.  This  is  a  matter  of  much  import 
with  regard  to  the  etiologic  role  which  spoiled  maize  is 
supposed  to  play. 

"  III.  It  is  declared  that  coimtries  in  which  maize  is  not 
grown  or  used  as  food,  or  only  exceptionally  so  used, 
even  though  contiguous  to  pellagrous  sections,  or  actually 
surrounded  by  them,  are  free  of  pellagra." 

[Lombroso,  Babes  and  Sion,  and  others  have  reported 
just  such  peculiar  instances.] 

"IV.  It  is  declared  that  a  change  of  food,  either  among 
individuals,  or  groups  of  individuals,  brings  constantly  a 
diminution  or  disappearance  of  pellagra,  or  vice  versa. 
There  are  also  many  reported  instances  of  this  kind.  Most 
writers  allege  that  recovery  may  take  place,  or  ameliora- 
tion occur  in  the  condition  of  pellagrins,  by  removing  from 
their  diet  all  maize  and  maize  products.  The  case  of 
Corfu,  in  this  connection,  is  regarded  as  such  a  notable 
instance  that  it  will  bear  quoting.  Typhaldos  (whose 
study  and  contributions  to  the  hterature  of  pellagra  have 
been  previously  mentioned)  states,  that  pellagra  was 
unknown  in  this  island  previous  to  1857,  and  that  up   to 


46  PELLAGRA. 

that  time  the  inhabitants  grew  their  own  maize,  which 
was  of  a  fine  quality,  but,  for  economic  reasons,  the  cul- 
ture of  grapes  became  almost  universal,  and  they  began  to 
subsist  on  the  imported  maize  of  very  poor  quality — that 
is,  spoiled  maize.  Pellagra  followed  and  became  endemic, 
and  he  found,  in  1866,  81  cases  there." 

Lavinder  next  groups  the  various  modifications  of  the 
maize  theory  in  the  following  lucid  manner: 

"  I.  The  idea  that  maize,  as  a  food  stuff,  is  wanting  in 
proper  nutritive  value.  This  conception  is  in  reality  no 
longer  held,  having  been  rather  effectually  discredited  by 
many  careful  analyses  of  maize,  which  show  that  this 
cereal  possesses  high  nutritive  value,  is  rich  in  fats  and 
nitrogenous  substances,  and  is  easily  assimilable." 

The  chemical  analysis  and  statement  of  the  dietetic 
value  of  com  in  the  beginning  of  this  chapter  show  that 
the  argument  concerning  the  deficiency  in  its  nutritive 
value  is  entirely  fallacious.  The  writer,  in  some  dietetic 
observations  conducted  several  years  ago,  found  that 
laboring  men,  on  a  diet  of  corn-bread  alone,  could  for  as 
much  as  a  week  keep  squarely  up  to  their  standard  of  effi- 
ciency. He  was  unable,  however,  to  keep  them  on  this 
diet  over  a  week,  not  that  they  were  suffering  from  any 
physical  infirmity,  but  simply  because  they  desired  to 
return  to  their  regular  "  bill  of  fare,"  and  the  persuasion  of 
the  writer  was  not  effective  enough  to  control  them. 

In  food  value  it  compares  very  favorably  with  rice, 
for  example,  which  constitutes  a  staple  article  of  diet 
among  the  numerous  classes  of  people  who  do  not  suffer 
from  pellagra.  Pellagra  is,  moreover,  not  infrequently 
found  among  well-nourished  individuals,  and  its  symptom- 
atology is  not  that  of  inanition. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       47 

"  II.  The  idea  that  good,  sound  maize  contains  certain 
toxic  substances  which  cause  pellagra.  This  is  another 
view  which  has  been  largely  discredited  by  the  absence  of 
pellagra  in  so  many  places  where  maize  is,  and  has  been, 
for  long  periods,  extensively  used  as  food. 

"It  is  also  worth  while  to  note  that  the  gross  distinc- 
tion between  sound  and  spoiled  maize,  in  the  opinion  of 
many  able  observers  is  not  always  easily  determined. 
Maize,  by  reason  of  its  high  fat  and  nitrogen  contents, 
seems  quite  subject  to  change  under  the  inJQuence  of  bac- 
terial growth,  and  grain  which  to  all  appearance  may  seem 
perfectly  sound  can  nevertheless  be  shown  to  be  spoiled 
or  damaged  to  a  greater  or  less  extent." 

The  writer  well  remembers  how,  when  a  lad,  he  used 
to  observe  the  care  with  which  corn  was  prepared  when  it 
was  "  milling  day,"  how  all  nubbins  or  defective  ears  were 
rejected,  and  how  the  small  ends  of  the  ears  were  broken 
off,  so  that  none  but  sound,  well-matured  corn  was  sent 
to  be  ground  into  meal.  This  custom  obtained  among  all 
the  farmers,  for  in  those  days  the  South  raised  its  own  food 
crops  to  a  major  extent,  nor  had  the  immense  and  fertile 
expanses  of  the  "  Golden  West  "  assumed  their  position  as 
"  granary "  for  these  states.  The  well- trained  noses  of 
farmers  or  housewives  could  detect  the  slightest  foreign 
odor,  and  luckless  was  the  miller  who  sent  back  musty  meal 
in  exchange  for  sound  and  wholesome  corn. 

Under  this  old  regime  there  was  no  pellagra  in  the 
South,  nor  did  it  ever  appear  until,  under  changed  condi- 
tions, brought  about  by  economic  reasons,  as  happened 
in  the  island  of  Corfu,  other  crops  took  the  place  of  corn — 
other  crops  that  brought  more  ready  money,  and  the  West 
was  called  on,  as  was  Egypt  in  the  days  of  Pharaoh. 


48  PELLAGRA 

In  the  Western  and  Middle  States,  as  corn  became  a 
staple  article,  the  problem  was  not  alone  to  transport  and 
sell  it,  but  to  house  it  in  the  immense  quantities  in  which 
it  was  produced.  The  consequence  was,  that  in  many  sec- 
tions the  corn  was  not  permitted  to  mature  in  the  fields, 
and  await  there  until  thoroughly  dried  before  it  was  put  in 
barns,  but  it  was  cut,  and  the  corn  on  the  stalks  was 
"  shocked  "  in  the  fields  until  it  was  convenient  to  mar- 
ket it.  In  this  semi-exposed  condition,  subjected  to  all 
the  varying  changes  of  the  weather,  the  corn  waited  some- 
times for  weeks,  and  then,  perhaps,  just  after  a  season  of 
rain,  or  when  the  atmosphere  was  humid  in  the  extreme, 
it  was  put  in  close  cars,  and  its  journey  began. 

If,  by  good  fortune,  it  reached  its  place  of  final  marketing 
in  wholesome  condition,  it  had  to  run  the  gauntlet  of 
different  wholesale  storage  depots,  of  warehouses  for  the 
mills,  where  often  dampness  abounded,  and  micro-organ- 
isms found  congenial  environment  for  bountiful  multipli- 
cation. 

Thus,  the  com,  that  was  originally  one  of  Nature's  best 
food-stuffs,  under  the  blighting  treatment  forced  by  com- 
mercial necessity  and  economic  exploitation,  became  an 
object  of  suspicion  in  many  quarters,  and  in  others  practi- 
cally imder  the  ban  of  conviction. 

This,  in  brief,  is  the  present  status  of  corn — the  com- 
mercial article  whose  safety  as  food  is  now  on  trial. 

"  III.  The  toxicochemical  idea,  to  continue  with  Dr. 
Lavinder,  that  under  the  influence  of  parasitic  growths 
(bacteria  or  moulds)  maize  may  undergo  certain  changes 
with  the  formation  of  one  or  more  toxic  substances  of  a 
chemical  nature   (exogenous  poisons).     This  idea  has   a 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       49 

host  of  adherents.  It  was  established  through  the  ad- 
mirable labors  of  Lombroso,  who,  as  said,  has  been  its 
great  advocate  and  exponent,  and  it  is  perhaps  to-day  the 
most  popular  of  all  the  various  phases  of  the  maize  theory. 
It  is  not  without  critics  and  antagonists,  however,  and 
Lombroso's  experimental  work  and  conclusions  have  been 
seriously  called  in  question  by  many  able  students  of  the 
disease. 

"  For  instance,  if  we  use  the  bacterium  maidis  as  an 
example,  we  may  put  it  that  it  is  inoffensive  per  se,  but 
releases  from  the  corn,  after  the  peculiar  toxicochemical 
action,  a  ptomain  that  works  the  harm. 

"  The  whole  gist  of  Lombroso's  argument  may  be  ex- 
pressed by  the  theory  that  in  pellagra  we  are  not  dealing 
with  a  primary  poison,  but  with  an  intoxication  produced 
by  poisons  developed  in  spoiled  corn  through  the  action 
of  certain  micro-organisms  in  themselves  harmless  to  man. 

"  Now,  while  Lombroso  experimentally  produced  several 
poisonous  oils  and  tinctures  from  spoiled  corn,  as  de- 
scribed previously,  unfortunately  he  could  not  incriminate 
any  particular  micro-organism.  Many  other  adherents 
have  followed  up  these  investigations,  producing  in  ani- 
mals and  fowls  symptoms  analogous  to  pellagra;  but 
similar  symptoms  have  also  been  produced  by  poisonous 
substances  obtained  in  the  same  way  from  other  cereals. 

"  Voluminous  reports  of  such  experimental  work  have 
been  adduced  by  Erba,  Hausemann,  Pellogio,  Gosio, 
Ferrati,  Mariani,  Belmondo,  PeHzzi,  Tirelli,  and  others 
with  practically  the  same  findings. 

"  It  is  of  much  interest  in  this  connection  to  know  that 
Babes    and    Manicatide    succeeded    in    neutralizing    the 


50  PELLAGRA 

toxicity  of  spoiled  maize  extract  with  the  serum  of  cured 
pellagrins;  and,  from  a  series  of  carefully  conducted  ex- 
periments, concluded  that  the  blood  of  pellagrins  con- 
tains a  substance  which  possesses  the  property  of  counter- 
acting the  toxic  action  of  the  extracts  of  spoiled  maize." 

The  theory  built  up  on  this  hypothesis  has  been  ex- 
tensively tried  out,  and  at  present  has  but  few  adherents. 

"IV.  The  toxic  infective  idea,  that  from  spoiled  maize 
there  are  formed  within  the  body  certain  toxic  substances 
(endogenous) . 

"  Neusser  advocated  the  view  that  under  some  cir- 
cumstances there  is  formed  in  maize,  largely  under  the 
influence  of  the  bacterium  maidis,  a  certain  '  receptive 
mother  substance'  which  later,  in  the  body,  underwent  a 
further  change.  Under  other  circumstances,  however,  he 
viewed  the  disease  as  a  direct  intoxication. 

"  De  Giaxa  attributed  great  importance  to  the  action 
of  the  colon  bacillus  on  ingested  maize.  His  idea  seems 
to  have  been  that  the  vegetating  properties  of  this  bacillus 
may  become  greatly  modified  on  a  culture  medium  of 
maize,  and  he  alleges  that  he  has  shown  the  production,  by 
the  colon  bacillus  on  maize  media,  of  specific  toxic  sub- 
stances." 

The  tendency  to  charge  the  colon  bacillus  with  various 
"  high  crimes  and  misdemeanors "  has  not  been  con- 
fined to  Italy  or  France,  for  one  eminent  American  gastro- 
enterologist  has  recently  proved  to  his  satisfaction  that 
the  colon  bacillus  alone  is  the  microscopic  malefactor  in 
the  production  of  pellagra. 

Passing  for  the  time  from  the  discussion  of  spoiled  corn 
and  corn  products  as  an  etiologic  factor  in  pellagra,  we 
desire  in  fairness  to  present  the  other  side. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       51 

In  opposition  to  the  "  zeistic "  doctrine  there  arose  a 
school,  especially  in  France,  and  a  group  of  investigators, 
led  by  Landouzy,  began  to  report  cases  of  pellagra  where 
it  was  claimed  no  corn  had  ever  been  ingested. 

This  brought  to  the  fore  Roussel,  that  deep  thinker  and 
trenchant  writer,  who  questioned  their  observations,  dis- 
credited their  diagnoses,  and  introduced  the  new  term 
"  pseudopellagra,"  which  he  claimed  fitted  their  cases. 

The  term  pseudopellagra  has  been  a  source  of  much 
confusion  in  the  literature  of  this  subject,  and  by  some  it 
has  been  considered  a  haven  of  refuge  for  their  opponents 
when  hard  pressed  by  the  anti-zeists. 

Sir  Patrick  Manson  takes  a  fling  at  it  with  the  remark, 
''  The  disease  is  pellagra  when  it  fits  in  with  the  orthodox 
theory  and  when  it  can  be  connected  in  any  way  with 
maize,  but,  when  this  is  not  possible,  the  disease  becomes 
pseudopellagra." 

Ceconni,  LeFrer,  and  several  other  French  writers 
speak  of  the  pellagrous  syndrome,  and  call  it  the  "  morbus 
miseriae."  They  go  so  far  as  to  contend  that  among 
alcoholics,  and  in  certain  cachectic  conditions,  more 
particularly  among  the  insane,  symptoms  may  arise 
so  closely  simulating  pellagra,  that  such  a  diagnosis  can  be 
reasonably  made.  In  other  words,  they  go  so  far  as  to 
deny  that  this  is  a  disease  sui  generis. 

The  tendency  to  implicate  some  protozoal  or  animal 
parasite  was  first  brought  forward  by  Dr.  Louis  W.  Sam- 
bon,  lecturer  on  Tropical  Medicine  at  the  Liverpool  School 
of  Tropical  Medicine,  who  was  detailed  for  three  months 
in  Italy,  where  he  studied  pellagra. 

Dr.  Sambon,  by  his  researches  on  the  sleeping-sickness, 


52  PELLAGRA 

and  his  tsetse-fly  theory,  which  has  since  been  proved, 
estabhshed  his  position  as  a  student,  whose  views  were 
worthy  of  respectful  consideration. 

Briefly  and  without  elaboration,  the  following  is  Sam- 
bon's  theory: 

y  Pellagra  is  not  due  to  maize,  either  good  or  bad,  be- 
cause— 

(i)  It  is  found  in  places  where  maize  is  neither  culti- 
vated nor  eaten. 

(2)  It  is  absent  from  many  places  where  maize  is  the 
staple  food  of  the  population. 

(3)  It  has  in  many  places  either  decreased  or  become 
more  prevalent  without  any  change  in  the  food  or  the 
people. 

(4)  Its  constant  and  pecuHar  distribution  does  not  agree 
with  the  very  irregular  and  ever-changing  distribution  of 
spoiled  maize. 

(5)  In  over  a  century  and  a  half,  since  the  maize  theory 
was  first  suggested,  no  one  has  been  able  to  prove  it. 

The  behef  that  the  disease  has  everywhere  followed  the 
introduction  of  corn  cultivation  is  unfounded.  Pellagra 
was  first  recognized  as  a  specific  disease  in  the  beginning 
of  the  1 8th  century,  but  this  does  not  prove  that  it  was  not 
prevalent  long  before  that  time. 

On  the  other  hand,  Dr.  Sambon  makes  the  following 
postulates  to  prove  that  pellagra  is  a  parasitic  disease 
because — 

(i)  For  years  the  person  affected  may  present  some 
seasonal  recurrences,  which  can  only  be  explained  by  a 
parasitic  agent  with  alternating  periods  of  activity  and 
latency. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       53 

(2)  It  shows  a  constant  and  characteristic  topographic 
distribution. 

(3)  It  shows  a  definite  seasonal  incidence. 

(4)  Its  symptoms,  course,  duration,  morbid  anatomy, 
as  well  as  its  theory,  are  similar  to  those  of  parasitic  dis- 
eases. 

(5)  Of  two  places  almost  contiguous,  one  may  be 
a£Fected,  the  other  not. 

Again,  he  contends  that  pellagra  is  an  insect-borne 
disease  because — 

(i)  It  is  limited,  like  malaria,  sleeping-sickness,  etc., 
to  rural  places,  and  more  especially  to  the  vicinity  of 
certain  water  bodies. 

(2)  It  has  a  definite  seasonal  incidence — spring  and 
autumn. 

(3)  It  effects,  to  a  large  extent,  a  certain  class  of  people 
— the  field  laborers. 

(4)  It  is  not  contagious,  and  neither  food  nor  water  can 
account  for  its  pecuKar  epidemiology. 

(5)  Within  its  endemic  centers  it  affects  all  ages  and  fre- 
quently whole  families. 

(6)  Outside  its  endemic  centers  only  adults  who  have 
visited  the  infection  areas  present  the  disease,  and  fre- 
quently only  one  or  two  members  in  a  family  are  affected. 

His  bill  of  indictment  against  the  simulium  reptans  is 
based  upon  the  following  proof: 

(i)  Simulium  is  found  in  the  torrents  and  swift  running 
streams  of  all  pellagra  districts. 

(2)  Simulium  has  the  peculiar  seasonal  distribution  of 
pellagra  (spring  and  autumn). 

(3)  Simulium  is  found  only  in  rural  districts.  It  is 
unknown  in  towns  and  villages.     It  does  not  enter  houses. 


54  PELLAGRA 

(4)  Simulium  explains  most  admirably  the  peculiar 
limitation  of  the  disease  to  field  laborers. 

(5)  Simulium  is  the  only  blood-sucking  insect  which  the 
British  field  commission  has  found  in  its  visits  to  numerous 
pellagrous  districts  in  Italy. 

(6)  Simulium  reptans,  like  anopheles  maculipennis ,  has 
a  world-wide  distribution  and  explains  the  wide  distribu- 
tion of  pellagra.     It  is  found  wherever  pellagra  is  found. 

(7)  Simulium  causes  epizootics  in  animals  in  America 
and  in  Europe. 

(8)  Professor  Mesnil  has  found  a  protozoal  organism  in 
simulium. 

These  statements  from  Sambon  are  given  principally  for 
their  historic  interest,  for  he  has  abandoned  the  "simulium 
theory," 

This  simulium  fly  belongs  to  the  diptera,  or  two-winged 
flies,  belonging  to  the  simuliidce  family. 

The  species  located  in  America  are  the  simulium  vents- 
tum,  and  the  simulium  pecarum,  the  buffalo  gnat.  In 
Italy  Sambon  found  three  varieties — simulium  reptans, 
simulium  ornatum,  and  simulium  pubescans.  The  last 
named  were  found  in  the  greatest  numbers. 

While  the  topographic  conditions  in  many  places  in  the 
United  States  are  similar  to  those  in  Italy,  where  the 
simulium  reptans  abounds,  this  particular  variety  is  not 
found  out  of  Europe,  with  the  exception  of  Greenland, 
according  to  the  authority  of  Dr.  L.  O.  Howard,  chief  of 
the  Bureau  of  Entomology,  United  States  Department  of 
Agriculture. 

Dr.  W.  D.  Hunter,  of  the  same  department,  says,  "  All 
the  information  at  hand  seems  to  show  that  in  this  country 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       55 

there  is  no  apparent  connection  between  pellagra  and 
simulium.  The  centers  where  simuUum  is  most  abun- 
dant are  along  the  Mississippi  Valley,  from  Baton  Rouge 
north  to  about  Cairo,  111.,  and  in  New  Hampshire,  Maine, 
and  New  York. 

"  From  a  priori  considerations,  if  there  is  anything  in 
the  simuHum  theory,  the  centers  of  pellagrous  infection  in 
the  United  States  should  be  in  the  localities  mentioned 
rather  than  in  the  Southeastern  States." 

Sambon's  ideas,  also,  that  pellagra  is  nearly  always  linked 
to  a  running  stream  are  not  proved  by  the  experience  and 
inquiries  of  the  writer.  Out  of  over  100  cases,  where 
this  phase  of  the  probable  exposure  was  carefully  gone  into, 
in  only  15  was  this  environment  positively  brought  out. 
Many  were  city  dwellers,  who  had  not  been  near  streams 
at  all;  others  had  been  raised  in  high  and  dry  localities, 
and  had  never  to  their  knowledge  been  bitten  by  "  sand 
flies." 

The  writer  must  confess  that  an  original  favorable  con- 
ception of  the  "  Sambon  theory  "  has  diminished  in  pro- 
portion as  he  has  honestly  endeavored  to  demonstrate  its 
truth,  until  now  he  is  unable  to  subscribe  to  it. 

That  pellagra  appears  in  those  who  have  "  never  eaten 
corn  or  corn  products "  is  continually  being  asserted. 
We  can  hardly  open  the  pages  of  a  medical  journal  without 
seeing  some  instance  of  this  sort  cited,  where,  with  an  icon- 
oclastic air,  Hke  the  "  three  tailors  of  Tooly  Street,  who 
resolved  that  the  earth  was  flat,"  the  narrators  seem  to 
think  the  zeistic  idea  has  been  relegated  to  the  Umbo  of 
discredited  theories. 

A  New  Orleans  observer  has  reported  a  case  of  pellagra, 


56  PELLAGRA 

which  for  quite  a  while  seemed  that  it  was  going  to  prove 
an  exception  to  Lombroso's  doctrine.  This  pellagrin  was 
a  married  woman,  who  had  been  raised  in  a  section  of 
country  and  in  a  family  where  com  was  considered  suitable 
food  for  horses  and  hogs,  but  not  for  people.  She  and  her 
husband  iterated  and  reiterated  the  solemn  declaration  that 
never  in  her  life  had  she  eaten  any  com  or  any  food  made 
from  corn,  when  accidentally  the  physician  learned  that 
she  was  addicted  to  the  use  of  corn  starch,  eating  a  pound 
or  more  each  day. 

This  morbid  appetite — amylophagia — is  not  very  un- 
common, as  may  be  Judged  by  the  fact  that  recently  the 
writer  has  known  of  three  cases  at  the  clinic  for  internal 
medicine  at  the  Atlanta  School  of  Medicine.  They  were 
women — one  white  and  two  colored — and  they  admitted 
the  craving  with  e\ddent  reluctance. 

That  corn  in  many  forms,  as  an  adulterant  and  other- 
wise, enters  into  many  articles  of  daily  consumption  is  an 
undoubted  fact. 

A  miller  recently  described  the  former  custom  of  adul- 
terating the  cheaper  grades  of  flour  with  "  corn  hearts," 
though  he  claimed  the  pure  food  laws  had  practically  put 
an  end  to  it. 

Dr.  J.  L.  Campbell  has  called  attention  to  the  fact 
that  most,  if  not  all,  of  the  inexpensive  candies  on  the 
market  have  glucose  as  their  base;  also  most  of  the  table 
syrups  contain  this  com  product. 

.  The  breakfast  cereals,  a  legion  of  which  are  constantly 
on  American  tables,  contain  more  or  less  corn.  We  are 
served  some  food  containing  com  on  our  uprisings  and  our 
downsittings,  so  that  it  behooves  no  one  to  lightly  say  that 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       57 

he  or  she  has  never  eaten  this  grain  or  anything  made 
from  it. 

Another  theory,  which  the  writer  will  incorporate  in  this 
work,  is  that  brought  forward  by  Dr.  G.  C.  Mizell,  that 
the  cause  of  pellagra  may  be  traced  to  the  ingestion  of 
"  semidried  edible  oils." 

The  writer  does  not  subscribe  to  this  theory,  nor  has  it  as 
yet  received  approbation  in  many  quarters,  but  that  the 
present-day  views  of  pellagra  may  be  adequately  reflected 
in  these  pages,  requires  that  Dr.  Mizell's  contentions  be 
accorded  a  reasonable  amount  of  space. 

Admitting  the  possibility  of  spoiled  maize  producing 
pellagra,  he  deems  it  impossible,  unless  the  diet  excludes 
all  other  food,  especially  fats.  He  further  opines  that 
the  fat  responsible  for  the  trouble  is  linolin,  a  neutral  fat, 
which  is  present  to  some  extent  in  all  semidrying  and 
some  drying  oils. 

Lest  this  gentleman  should  be  misquoted,  his  exact  words 
will  be  used  in  the  following  paragraphs : 

"  When  hnolin  is  consumed  in  large  quantities  it  is  de- 
posited in  the  tissues  as  linolin.  When  it  undergoes  oxida- 
tion poisonous  products  are  formed.  These  oxidation 
products  are  suspected  of  producing  the  disease.  This 
would  necessarily  mean  that  the  disease  is  biochemic 
in  nature.  The  amount  of  linolin  consumed  will  depend 
on  the  percentage  present  in  the  oil  and  the  amount  of  oil 
eaten.  Some  of  the  semidrying  oils  contain  such  a  small 
percentage  of  linolin,  it  is  probable  that  they  would  not 
be  deleterious  to  health.  This  point  needs  to  be  em- 
phasized, as  it  appears  that  the  quantity  consumed  is 
important.     .     . 


58  PELLAGRA 

" .  .  .  Keep  in  rrdnd  that  the  import  or  production 
of  oil  does  not  mean  that  the  oil  is  always  eaten.  Many 
nations  import,  and  some  produce  large  quantities  of  oil 
of  this  class  for  commercial  purposes.  Germany  is  one  of 
these.  Germans  are  not  an  oil-consuming  people.  The 
chief  substitute  for  animal  fat  in  Germany  is  a  non-dr}dng 
oil,  viz.,  cocoanut  butter,  the  daily  production  of  which 
is  estimated  at  one  hundred  tons.  A  law  requires  the  use 
of  lo  per  cent,  of  sesame  oil  in  the  manufacture  of  mar- 
garine. This  amount  I  do  not  believe  is  sufficient  to  cause 
disease.  It  appears  that  it  is  necessary  to  introduce 
comparatively  large  amounts  of  linolin  into  the  body  in 
order  to  produce  pellagra. 

"  Below  is  given  a  table  of  the  semidn,dng  oils  and 
nativity.  Many  minor  oils  are  omitted,  being  less  used, 
and  only  supplementing  the  more  common: 

On,  or —  Nattvity. 

Cotton  seed United  States,  India,  Egypt,  China,  Russia,  Brazil, 

^Mexico,  Japan,  Turkey,  etc. 
Sesame  seed The   Levant,   India,   Egypt,   Java,   Siam,   Algeria, 

East  and  West  Coast  of  Africa,  South  Rhodesia. 

Maize United  States,  Argentina,  etc. 

Beechnut Manufactured  in  Europe  in  17 13,  but  not  at  present. 

Pinot Brazil  and  Guiana. 

Kapok East  and  West  Indies,    South   America,   Mexico, 

.\frica. 

Brazil  nut South  x\merica. 

Luffa  seed East  India. 

Rape  seed India,  Northern  France. 

Piimpkin  seed Austria,  Hungary,  Russia. 

Sunflower  seed Hungar>^,    India,    China,    South    and    Southwest 

Russia. 
Poppy  seed Asia   Minor,   Persia,  India,  Egj-pt,  South  Russia, 

Northern  France. 

"  Poppy-seed  oil  is  a  dr}dng  oil,  but  contains  a  large 
percentage  of  linolin ,  and  is  an  edible  oil  of  extensive  use. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       59 

Some  of  the  above  oils  contain  a  low  percentage  of  linolin 
and  may  be  of  no  importance  as  an  etiologic  factor. 

"  Laws  regulating  the  importation  of  seed  oils  into 
some  olive-growing  countries  have  in  recent  years  been 
enacted,  so  as  to  protect  the  home  industry.  Some  coun- 
tries growing  enormous  quantities  of  oleaginous  seed 
export  the  seed,  and  consume  very  little  or  none  of  the 
oil.     Such  is  the  case  in  China  and  Japan. 

"  The  people  of  Southern  Europe  are  noted  oil  con- 
sumers. Italy  is  the  second  largest  olive-oil-producing 
country  in  the  world.  Notwithstanding  the  enormous 
quantity  of  olive  oil  produced,  much  oil  is  imported. 
They  are  also  the  largest  exporters  of  comestible  oils  in 
this  region, 

"  Large  amounts  of  semidrying  oils  are  imported. 
These  are  used  at  home,  and  exported  as  edible  oils  under 
various  labels,  and  used  to  adulterate  olive  oil.  These 
semidrjdng  oils  are  cheaper  than  olive  oil,  hence  are 
consumed  by  the  poor.  Cotton-seed  oil  was  probably 
imported  from  Marseilles  long  before  it  was  thought  of  in 
America.  At  the  present  time  it  is  well  known  in  the 
Italian  market. 

"  In  recent  years  the  demand  has  increased.  It  is 
stated  that,  when  cultivation  of  lupines  was  introduced 
into  certain  regions,  enabling  the  farming  class  to  raise 
stock  and  dispense  with  maize  as  a  food,  pellagra  disap- 
peared. It  is  probable  that,  instead  of  pellagra  disap- 
pearing for  the  above-named  reason,  it  was  in  reality  due 
to  a  change  from  vegetable  oil  to  animal  fat  consump- 
tion.    .     .     . 

"  My  conclusion  from  investigation  of  the  seed-oil  indus- 


6o  PELLAGRA 

try  is  that  since  1817,  when  the  first  seed-crushing  mill  was 
put  into  operation  in  Marseilles,  there  has  been  an  almost 
unlimited  supply  of  seed  oils.  The  habits  of  the  various 
nations  and  individuals  have  alone  operated  in  determin- 
ing the  extent  of  oil  consumption.  Often  the  need  of  cheap 
food  has  determined  the  selection.  Until  the  mills  began 
crushing  seed  there  was  no  pellagra  in  France.  The 
peasantry  were  afflicted  because  the  poor  bought  cheap 
food.  In  the  United  States  the  selection  of  edible  fat 
was  not  determined  by  price  until  the  cost  of  provisions 
increased  about  1908.  Until  this  date,  purity  of  food 
was  the  determining  factor  to  a  great  extent.  It  is  true 
that  the  manufacturers  have  appealed  to  patronage  from 
both  standpoints.  They  made  a  cheap  article  for  the 
poor  and  a  high-priced  article  for  those  in  better  circum- 
stances. Dyspeptics  have  been  shown  that  the  oil  is  more 
digestible.  The  fastidious  are  told  that  the  oil  is  pure 
vegetable  oil,  clean,  and  highly  nutritious.  The  Pure 
Food  and  Drugs  Act  is  stamped  upon  each  package  as  a 
guarantee  of  purity  and  wholesomeness.  The  unsuspect- 
ing pubHc,  depending  upon  the  guardianship  of  the  govern- 
ment stamp,  has  adopted  cotton-seed  oil  as  a  regular  article 
of  diet.  Various  cooking  substances,  without  a  single  in- 
dication of  their  nature,  are  coming  uito  the  market  with- 
out even  the  distributing  agent  beiag  able  (or  wiUing) 
to  name  the  contents  of  the  package.  People  are  con- 
suming these  preparations  without  question  because  the 
government  stamp  is  upon  them.  This  being  the  case  in 
our  own  country,  who  will  doubt  that  the  cheap  comestible 
oils  shipped  (even  as  pure  oUve  oil)  into  oil-consuming  com- 
munities are  made  up  largely  of  semidrying  oil? 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       6 1 

"Note  the  progress  of  pellagra  in  the  United  States. 
It  started  in  the  South,  where  oil  consumption  began,  and 
only  after  it  began.  Illinois  should  be  placed  with  the 
South,  both  as  to  oil  consumption  and  pellagra.  More 
pellagra  has  appeared  in  Cahfornia  than  any  other  western 
state.  It  is  significant  that  she  also  consumes  more 
cotton-seed  oil,  A  map  of  cotton-seed  oil  consumption 
in  the  United  States  would  serve  as  a  map  showing  the 
geographic  distribution  of  pellagra,  except  as  affected  by 
climate.  Nations  that  have  remained  consumers  of  non- 
drying  oils  are  not  aflflicted  with  pellagra.  Some  of  them 
have  eaten  maize,  just  as  the  inhabitants  of  the  United 
States  have  for  several  centuries,  without  having  de- 
veloped pellagra.     .     .     . 

"  Experiments  upon  animals  indicate  that  pellagra  may 
be  caused  by  eating  less  than  one  ounce  of  oil  daily.  If  this 
is  true,  oil  may  be  consumed  for  medicinal  purposes  in 
sufficient  quantity  to  produce  the  disease,  and  olive  oil 
should  not  be  administered,  unless  of  known  quality." 

This  is  a  brief  attempt  to  give  the  salient  features  of  Dr. 
MizelFs  theories,  which,  after  three  years,  are  still  unproved. 

The  conscientious  narrator  must  admit  that  the  cause  of 
pellagra  is  still  to  a  great  extent  an  unsolved  problem. 
The  zeist  doctrine  is,  on  the  present  state  of  science,  in- 
susceptible of  direct  proof  or  direct  disproof.  There  are 
many  reasons  why  it  cannot  be  disproved.  It  is  impos- 
sible to  show  that  any  person  whose  food  partook  of  corn 
products  ate  only  healthy  corn.  If  the  corn  was  originally 
healthy  it  might  have  been  badly  kept,  or,  if  well  kept, 
it  might  have  been  poorly  treated  after  being  ground  into 
meal;  or  even  the  meal  might  have  been  wholesome,  but  the 


62  PELLAGRA 

bread  or  other  articles  of  food  made  from  it  might  have  been 
allowed  to  become  spoiled,  or  contaminated  by  contiguous 
agencies.  So,  when  one  has  at  any  time  eaten  corn  prod- 
ucts, there  is  a  chance  that  it  was  not  absolutely  sound. 

The  idea  advanced  some  time  back  by  the  antizeists  that 
pellagra  was  a  "disease  of  poverty"  has  been  exploded, 
though  at  present  Dr.  Goldberger  is  arguing  somewhat 
\/  along  that  line.  The  many  cases  in  persons  of  wealth  and 
refinement,  where  environmental  conditions  were  all  that 
could  be  wished,  have  effectually  put  an  end  to  that  chimera. 
The  more  positive  doctrines,  as  collated  by  the  late  W. 
Bayard  Cutting,  Jr.,  may  be  enumerated  as  follows: 

(i)  That  which  attributes  pellagra  to  corn  itself,  not  to 
spoiled  com.  This  explanation  is  inadequate.  If  com  is 
lacking  in  certain  nutritive  quahties — in  gluten,  in  nitrog- 
enous matter — so  is  rice,  which,  nevertheless,  does  not 
produce  pellagra.  (The  nutritive  qualities  of  com  have 
already  been  favorably  considered.)  If  corn  contains  a 
poison,  how  can  so  many  nations  consume  it  with  im- 
punity? 

(2)  That  which  admits  spoiled  com  as  the  cause,  but 
thinks  that  the  poison  enters  not  as  a  toxin  ready  made, 
but  as  a  bacterixun  (bacterium  maidis). 

(3)  Those  which  attribute  the  poison  to  other  agencies 
than  the  penicillia — to  the  aspergilli,  for  instance,  or  to 
the  bacterium  maidis,  or  to  a  combination  of  these  micro- 
organisms. 

(4)  Those  which,  while  admitting  the  direct  poisoning 
from  com  as  one  cause  of  pellagra,  attach  considerable 
importance  to  other  elements — heredity,  for  instance,  or 
the  consumption  of  alcohoHc  Hquors  made  from  com. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       63 

As  far  as  Italy  is  concerned,  they  admit  that  the  con- 
sumption of  corn,  and  especially  spoiled  corn,  is  at  the 
root  of  the  disease,  and  official  measures  including  this 
hypothesis  are  in  motion,  which  will  be  covered  later 
under  the  head  of  prophylaxis. 

Among  predisposing  etiologic  factors  poverty,  no  doubt, 
plays  an  important  role. 

That  unhygienic  homes  and  surroundings,  that  ig- 
norance begotten  of  poverty,  and  continued  by  reason  of 
poverty,  may  dwarf  both  the  body  and  the  intellect,  im- 
pairing the  normal  resistance  faculty,  and  making  the 
body  a  more  inviting  host  for  the  powers  of  disease;  that 
cheap,  often  synonomous  with  adulterated,  food  should 
impair  the  digestive  powers,  la)dng  foundations  for  various 
stomach  and  intestinal  ills — all  these  can  serve  as  un- 
doubted factors  for  the  development  of  pellagra  as  well  as 
any  other  toxic  or  infectious  disorder.  This  has  been  con- 
clusively shown  by  the  studies  of  the  Thompson-McFadden 
Commission,  whose  labors  will  later  receive  extended  com- 
ment.   Let  them  be  quoted  as  follows: 

"Another  feature  of  our  field  work  in  19 13  has  been  the 
survey  of  communities  offering  marked  contrast  in  certain 
particulars.  All  the  mill  villages  of  Spartanburg  County 
were  found  to  be  endemic  centers  of  pellagra.  All  these 
villages  have  been  using  unscreened  surface  or  pail  privies 
for  the  disposal  of  human  excrement.  A  careful  survey  of 
two  other  mill  villages,  one  in  Oconee  County  and  the  other 
in  Chester  County,  S.  C,  failed  to  disclose  any  case  of 
pellagra  which  had  certainly  originated  in  these  villages, 
although  cases  which  had  originated  elsewhere  were  present. 
In  these  villages  every  house  was  provided  with  a  water- 


64  PELLAGRA 

carriage  flush  closet  connected  with  a  sewer,  and  this 
seemed  to  be  their  most  important  distinguishing  charac- 
teristic. In  the  city  of  Spartanburg,  S.  C,  the  active  foci 
of  the  disease  were  confined  to  those  sections  of  the  city 
in  which  imscreened  surface  or  pail  privies  were  in  use. 
Of  the  241  cases  in  the  city  of  Spartanburg  itseh,  for  which 
data  on  disposal  of  sewage  were  available,  it  was  found  that 
230  were  using  unscreened  surface  or  pail  privies.  In  only 
1 1  instances,  or  5  per  cent,  of  the  total,  was  a  water-carriage 
system  of  disposal  employed,  and  several  of  these  cases 
arose  in  sections  of  the  city  where  unscreened  surface  privies 
were  in  use  by  their  neighbors,  some  of  whom  were  pellag- 
rins. In  certain  hospitals  for  the  insane  we  have  ascer- 
tained that  pellagra  is  usually  most  prevalent  and  persistent 
in  the  wards  housing  untidy  patients." 

Apart  from  these  considerations,  however,  poverty  wields 
no  specific  influence. 

That  heredity  is  a  predisposing  factor  seems  fairly 
well  proved.  The  writer  has  records  of  81  instances  where 
pellagra  was  observed  in  the  second  or  third  generation; 
and  at  present  has  under  observation  28  cases  where 
pellagra  has  occurred  (mostly  fatally)  in  the  parents  or 
grandparents. 

One  instance,  where  an  infant  was  bom  of  a  pellagrous 
mother,  was  reported.  It  seemed  that  conception  took 
place  during  a  remission  of  the  disease,  but  the  confinement 
came  on  during  the  recrudescence.  The  infant  Hved 
only  two  months,  never  thrived,  and  its  skin  was  harsh 
and  dry  during  the  whole  of  its  brief  life. 

The  mother  was  treated  a  short  time  for  the  disease, 
but,  after  a  period  of  improvement,  ceased  to  report,  and 
the  final  outcome  of  her  iUness  was  unknown. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       65 

The  children  of  pellagrins  also  seem  to  fall  an  easy 
prey  to  other  diseases,  notably  those  ailments  of  the 
alimentary  tract.  At  the  clinic  for  gastro-intestinal  dis- 
ease at  the  Atlanta  School  of  Medicine  hardly  a  week 
passes  but  what  some  patient  reports  pellagra  in  one  of 
the  parents. 

In  regard  to  race  some  interesting  features  have  been 
observed.  The  Caucasian  race  seems  more  subject  to  it 
than  the  yellow  or  red  race.  Among  the  white  race,  also, 
the  writer  has  noticed  a  preponderance  among  the  blondes, 
perhaps  because  of  their  being  more  vulnerable  to  the 
sun's  rays. 

Dr.  Babcock's  statement  that  in  the  South  the  disease 
is  more  common  among  the  negroes  than  the  whites  has 
not  been  verified  by  the  writer.  That,  when  among  the 
negroes,  it  more  frequently  attacks  the  women  may  be 
admitted,  but,  among  several  hundred  observed  during 
the  last  three  years,  the  African  race  furnished  only  a 
small  percentage. 

Dr.  Bernard  Wolff,  of  Atlanta,  has  adduced  the  novel 
theory  that  the  Jews  are  practically  exempt  from  pellagra. 
This  brings  up  indirectly  the  question  of  heredity,  for 
the  Jewish  blood  is  probably  more  free  from  admixture 
with  other  races  than  any  other.  Dr.  Wolff  has  been 
able  to  locate  only  four  pellagrins  among  this  race,  and 
the  writer  has  never  seen  one. 

Sex  is  not  supposed  to  exert  any  special  influence,  though 
about  65  per  cent,  of  the  cases  coming  under  our  obser- 
vation have  been  females.  This  has  not  been  the  ex- 
perience of  others.     It  would   appear  that   the  nervous 

cases  have  largely  been  females. 
5 


66  PELLAGRA 

Habits  act  on  the  principles  of  lessened  resistance. 
Several  alcoholics,  and,  strange  to  say,  those  who  pre- 
ferred corn  whisky,  have  been  under  observations  with 
uniformly  fatal  results. 

One  of  the  most  fulminant  cases  the  writer  has  ever 
seen  occurred  in  a  brawny  mountaineer,  who,  as  he  ex- 
pressed it,  was  "  a  dear  lover  of  corn  liquor,"  and  who 
lived  only  about  three  weeks  after  the  pellagra  was  notice- 
ably developed. 

Venereal  excesses,  mental  strain,  pregnancy,  and  frequent 
child-bearing  all  act  in  the  same  way — no  special  predis- 
position, but  lessened  resistance. 

With  few  exceptions  it  does  not  attack  the  very  young. 
Most  writers  claim  that  infants  do  not  suffer  with  pellagra 
imless  they  are  fed  on  spoiled  corn  products,  and  in  this 
the  writer  agrees. 

No  cases  under  five  years  of  age  have  been  personally 
known,  and  very  few  under  ten.  This  malady  seems  to 
attack  by  preference  those  between  the  ages  of  twenty  and 
forty — ages  when  they  can  be  most  useful  to  themselves, 
their  families,  and  the  community  at  large.  When  it  at- 
tacks those  over  fifty,  the  duration  is  either  short  or  a  con- 
dition of  dementia  supervenes. 

Occupation  was  thought  at  one  time  to  possess  a  large 
influence,  but  this  idea  is  weakening  at  present.  In  Italy 
it  has,  of  course,  attacked  the  rural  and  agricultural  popula- 
tion, as  has  been  proved  time  and  again.  In  America, 
however,  and  especially  in  the  South,  occupation  has 
shown  but  scant  influence. 

At  present  the  writer  has  under  observation  several 
pellagrins,  who  are  in  easy,  almost  affluent  circumstances. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       67 

One,  an  unmarried  lady  of  about  forty  from  an  adjoining 
state,  has  been  in  her  community  a  leader  in  civic  reforms, 
an  exemplar  in  hygiene,  a  stickler  for  correct  manners  of 
living. 

Another  is  a  young  woman,  the  petted  darling  of  wealthy 
parents,  whose  every  wish  was  always  gratified,  and  whose 
surroundings  carried  every  comfort  that  money  could  buy. 

Along  with  these  cases  come  farm  laborers,  horny- 
handed,  with  the  tan  of  sun  and  weather  on  their  faces; 
operatives  in  cotton  mills,  pallid,  with  flat  chests  and 
anemic  complexions;  dusky-hued  sons  and  daughters  of 
Africa — all  suffering  from  the  same  dread  pellagra. 

The  spring  season  certainly  has  an  influence  in  bringing 
out  the  latent  symptoms  of  this  disease.  How  much 
actual  influence  the  heat  and  sun  have  on  indirectly  caus- 
ing it  by  increasing  parasitic  growths,  and  hastening  the 
putrefaction  of  poorly-kept  food  products,  is  only  a  matter 
of  conjecture.  That  the  actinic  rays  of  the  sun  are  in- 
strumental in  producing  the  erythema  cannot  be  gain- 
said. Furthermore,  after  the  erythema  is  apparently 
healed,  the  sun,  or  even  bright  light,  can  bring  it  back 
again,  is  the  experience  of  the  writer  and  many  others. 

Certain  it  is  that  pellagra  is  a  disease  of  summer  and 
warm  weather,  and  that  spring  and  summer  exert  a  dele- 
terious effect,  while  cold  weather  is  beneficial,  is  known  to 
all  who  have  had  any  experience  with  it. 

It  has  been  claimed  in  Italy  that  humidity  exerted  a 
predisposing  influence,  and  that  the  disease  was  more 
rife  after  a  wet  summer  than  a  dry  one.  Such  has  not 
been  noted  in  the  United  States,  nor  in  the  South,  though 
the  few  years  of  our  observation  here  are  not  sufficient  for 
an  intelligent  opinion  on  this  score. 


68  PELLAGRA 

Probably  the  most  scientific  and  painstaking  series  of 
investigations  as  to  the  etiology  of  pellagra  have  been  fur- 
nished by  the  Thompson-McFadden  Pellagra  Commission, 
a  body  of  laborers  made  possible  by  the  munificence  of  Col. 
Robert  M.  Thompson,  of  New  York  City,  and  Mr.  J.  H. 
McFadden,  of  Philadelphia.  The  funds  thus  supplied 
supported  a  research  expedition  for  the  study  of  pellagra  in 
the  United  States,  the  members  of  the  body  being  one 
designated  by  the  Surgeon- General  of  the  Army,  one  by  the 
Surgeon-General  of  the  Navy,  and  one  by  the  authorities 
of  the  New  York  Post-Graduate  Medical  School.  The 
commission  was  constituted  as  follows:  Captain  J.  F.  Siler, 
Medical  Corps,  U.  S.  Army,  representing  the  Medical 
Corps  of  the  U.  S.  Army;  Passed- Assistant  Surgeon  P.  E. 
Garrison,  U.  S.  Navy,  representing  the  Medical  Corps  of 
the  U.  S.  Navy,  and  Dr.  W.  J.  McNeal,  Professor  of  Bac- 
teriology and  Pathology,  New  York  Post-Graduate  Medical 
School,  representing  that  institution.  In  the  spring  of  19 12 
the  Bureau  of  Entomology  of  the  U.  S.  Department  of 
Agriculture  detailed  Messrs.  A.  H.  Jennings  and  W.  V. 
King  to  aid  the  commission  by  investigating  the  possible 
etiologic  relation  between  insects  and  pellagra. 

A  field  headquarters  was  established  in  the  South  early 
in  June,  191 2,  and,  in  collaboration,  biologic,  pathologic, 
and  chemic  studies  were  undertaken  in  the  laboratories  of 
bacteriology,  pathology,  and  pathologic  chemistry  of  the 
New  York  Post-Graduate  Medical  School  under  the  super- 
vision of  Dr.  Jonathan  Wright,  Director  of  Laboratories,  and 
Dr.  W.  J.  McNeal,  a  member  of  the  commission.  Other  re- 
searches along  these  lines  were  carried  out  by  Drs.  0.  S. 
Hilhnan,  R.  M.  Taylor,  V.  C.  Myers,  and  M.  S.  Fine. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       69 

For  reasons  considered  sufificient,  Spartanburg,  S.  C,  and 
the  county  of  the  same  name  were  made  field  headquarters, 
and  the  disease  was  there  studied  most  intensively.  The 
epidemiologic  investigations  have  led  to  the  accumulation 
of  a  very  large  mass  of  data  concerning  the  occurrence  and 
distribution  of  pellagra  in  Spartanburg  County  and  city, 
in  regard  to  the  cases  themselves  and  their  conditions  in  life. 

As  a  fitting  corollary  to  the  field  work  was  laboratory 
work  in  New  York,  which  was  accompHshed  by  sending 
patients  suffering  from  this  disease  from  the  field  headquar- 
ters in  South  Carolina  to  the  Post-Graduate  Hospital  in 
New  York  City. 

It  would  be  impracticable  to  include  all  of  the  interesting 
data  furnished  by  these  painstaking  and  conscientious 
gentlemen,  but  the  several  conclusions  will  be  given. 

Summary  of  first  "Progress  Report"  covering  work  of 
1913: 

"(i)  The  supposition  that  the  ingestion  of  good  or  spoiled 
maize  is  the  essential  cause  of  pellagra  is  not  supported  by 
our  study. 

"(2)  Pellagra  is,  in  all  probability,  a  specific  infectious 
disease  communicable  from  person  to  person  by  means 
at  present  unknown. 

"(3)  We  have  discovered  no  evidence  incriminating  flies 
of  the  genus  Simulium  in  the  causation  of  pellagra,  except 
their  universal  distribution  throughout  the  area  studied. 
If  it  is  distributed  by  a  blood-siicking  insect,  Stomoxys 
calcitrans  would  appear  to  be  the  most  probable  carrier. 

"(4)  We  are  inclined  to  regard  intimate  association  in  the 
household  and  the  contamination  of  food  with  the  excretion 
of  pellagrins  as  possible  modes  of  distribution  of  the  disease. 


70  PELLAGRA 

"(5)  No  specific  cause  of  pellagra  has  been  recognized." 

In  the  last  report  of  this  Commission,  published  in  the 
Archives  of  Internal  Medicine,  January,  1915,  a  number  of 
later  conclusions  are  adduced. 

A  synopsis  of  their  statistics  as  to  age  of  pellagrins  is  as 
follows:  "Pellagra  was  absent  or  very  rare  in  children  under 
two  years  of  age,  only  very  slightly  prevalent  for  the  five 
years  following  puberty  in  both  sexes,  and  only  slightly 
prevalent  in  adult  males  under  fifty  years  of  age.  On  the 
other  hand,  it  was  enormously  prevalent  and  severe  in 
females  from  twenty  to  forty  years  of  age,  somewhat  less 
prevalent  and  nearly  always  mild  in  children  of  both  sexes 
from  two  to  ten  years  of  age,  and  almost  equally  prevalent 
in  old  people  of  both  sexes.  These  features  of  the  age  and 
sex  distribution  are  believed  to  be  due  in  part  to  differences 
in  physiological  resistance  to  pellagra  and  in  part  to  differ- 
ences in  frequency  and  extent  of  exposure  to  the  disease, 
especially  by  proximity  to  or  association  with  other  pellag- 
rins." 

Summary  of  last  report: 

"(i)  The  geographical  distribution  of  pellagra  in  Spartan- 
burg County,  S.  C,  has  been  uneven,  the  morbidity  being 
much  higher  in  and  near  the  large  centers  of  population 
and  especially  in  the  cotton-mill  villages. 

"(2)  Pellagra  was  found  to  be  about  three  times  more 
prevalent  in  the  white  race  than  in  the  negro  population  of 
this  county.  This  ratio  is  not  regarded  as  a  true  measure  of 
the  relative  racial  resistance  to  the  disease,  but  rather  as 
the  end-result  of  the  influence  of  several  factors. 

"(3)  The  substance  of  this  paragraph  in  report  has  been 
given  in  synopsis  above. 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       71 

"(4)  The  peculiarities  of  age  and  sex  distribution  are 
believed  to  be  due  in  part  to  differences  in  physiological 
resistance  to  the  disease,  and  in  part  to  differences  in  degree 
and  frequency  of  exposure  to  the  causative  factors,  among 
which  proximity  to  or  association  with  pellagrins  seems  to 
be  important. 

"(5)  No  direct  relation  of  occupation  to  pellagra  morbid- 
ity was  discovered.  Indirectly,  by  determining  economic 
status  and  environment,  occupation  was  found  to  have  an 
important  bearing  on  the  prevalence  of  the  disease." 

Up  to  the  present  the  individual  members  of  the  Com- 
mission have  not  committed  themselves  to  any  statement 
as  to  the  etiology  of  pellagra,  though  Dr.  J.  F.  Siler,  in  a 
carefully  worded  communication,  writes:  "We  feel  that  when 
all  the  information  which  we  have  collected  has  been  brought 
together  and  analyzed,  that  it  will  indicate  very  strongly 
from  the  epidemiological  standpoint  that  pellagra  is  a  low- 
grade  infection  of  some  kind.  We  are  inclined  to  believe 
that  the  primary  lesions  occur  in  the  intestinal  canal.  We 
also  feel  very  strongly  that  it  is  necessary  that  predisposing 
factors  be  considered  in  the  etiology  of  pellagra,  and  one  of 
the  most  important  predisposing  factors  is  diet  (and  nutri- 
tion) .  We  do  feel,  however,  that  it  is  not  possible  to  explain 
pellagra  from  the  viewpoint  of  a  deficient  diet  alone." 

Pellagra  and  Potable  Waters.— In  a  recent  monograph 
of  nearly  200  pages  Alessandrini  and  Scala  have  presented 
a  series  of  epidemiologic  studies  on  pellagra,  which  led  them 
to  regard  the  disease  as  etiologically  related  to  potable 
waters  used  in  pellagrous  sections. 

Their  experimental  work  was  conducted  on  guinea-pigs, 
rabbits,  dogs,  and  monkeys.     It  consisted  in  the  injection 


72  ,  PELLAGRA 

and  ingestion  of  colloidal  solutions  and  gelatinous  suspen- 
sions made  from  the  potable  waters;  along  with  numerous 
variations  in  the  diet  of  the  animals,  especially  with  refer- 
ence to  a  diet  of  maize.  In  some  experiments  they  made 
additions  to  their  solutions  of  certain  salts,  notably  of  cal- 
cium, sodium,  and  aluminum,  for  the  purpose  of  testing  the 
action  of  certain  electrolytes  on  the  colloidal  silica  or  of  the 
contemporaneous  action  of  the  two  (that  is,  colloidal  silica 
and  electrolytes)  on  the  organism. 

In  an  analysis  and  discussion  of  results  the  authors  ex- 
press the  conviction  that  they  have  produced  in  their  ani- 
mals a  chronic  intoxication  which  not  alone  in  essential 
features  but  even  in  details  closely  approximate  pellagra  as 
seen  in  man.  This  they  assert  is  true  not  only  of  clinical 
phenomena,  but  also  of  morbid  pathologic  changes. 

This  is  their  condensed  argument:  "Colloidal  silica  dis- 
plays more  or  less  affinity  for  mineral  salts,  and  from  meta- 
bolic studies  on  dogs  under  experiment,  without  doubt,  silica 
in  the  animal  organism  acts  by  accumulating  mineral  sub- 
stances, and  produces  in  consequence  a  destruction  of  tis- 
sues. Therefore  it  seems  to  us,  without  doubt,  that  the 
silica  fixes  the  mineral  salts  on  the  proteins  of  the  tissues 
with  a  continuous,  incessant  action  quite  similar  to  the 
action  of  an  enzyme  or  diastase."  Continuing,  they  opine 
that  "conditions  exist  in  the  formation  of  these  compounds 
of  protein  substances  with  mineral  salts  by  which  the  acids 
of  such  salts  are  Hberated,  because  there  is  a  tendency  in 
said  compounds  to  pass  from  the  state  of  metallo-acido- 
protein  to  that  of  metallo-protein." 

By  further  argument,  analysis,  and  experimentation  they 
arrive  at  their  final  conclusion  that  "pellagra  is  a  malady 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       73 

caused  by  the  forced  retention  of  mineral  salts,  which,  in 
turn,  produces  a  liberation  of  acids  in  excess  of  the  needs      ' 
of  the  peculiar  organism;  or,  in  other  words,  pellagra  is 
nothing  more  than  a  mineral  acidosis  with  all  of  its  con- 
sequences." 

The  writer  has  no  special  comment  on  these  ingenuous 
arguments,  simply  including  them  to  ''make  the  record 
complete." 

Elsewhere  in  this  volume  mention  is  made  of  the  fact  that 
at  no  time  under  the  observation  of  the  writer  has  a  nurse 
or  attendant  of  one  or  many  cases  of  pellagra  developed  the 
disease. 

In  a  recent  article  (Reprint  No.  203,  Public  Health 
Reports)  Dr.  Joseph  Goldberger,  Surgeon  U.  S.  PubHc 
Health  Service  in  Charge  of  Pellagra  Investigations,  re- 
marks: "In  considering  the  significance  of  various  institu- 
tional reports,  it  is  to  be  recalled  that  at  all  of  these  insti- 
tutions the  ward  personnel,  nurses,  and  attendants  spend  a 
considerable  proportion  of  the  twenty-four  hours,  on  day 
or  night  duty,  in  close  association  with  the  inmates;  indeed, 
at  many  of  these  institutions,  for  lack  of  a  separate  building 
or  special  residence  for  the  nurses,  these  live  right  in  the 
ward  with  and  of  necessity  under  exactly  the  same  conditions 
as  the  inmates. 

"It  is  striking,  therefore,  that  although  many  inmates 
develop  pellagra  after  varying  periods  of  institutional  resi- 
dence, some  even  after  ten  to  twenty  years  of  institutional 
life,  and,  therefore,  it  seems  permissible  to  infer,  as  the  result 
of  the  operation  within  the  institution  of  the  exciting  cause 
or  causes,  yet  nurses  in  attendance  living  under  identical 
conditions  appear  uniformly  to  be  immune.     If  pellagra  is 


74  PELLAGRA 

a  communicable  disease,  why  should  there  be  exemption  of 
the  nurses  and  attendants?" 

Dr.  Goldberger  has  given  the  etiology  of  pellagra  careful 
study,  and  his  theories  are  worthy  of  consideration.  They 
will  be  given  verbatim : 

"The  explanation  of  the  peculiar  exemption  under  dis- 
cussion will  be  found  in  the  opinion  of  the  writer  in  a  differ- 
ence in  the  diet  of  the  two  groups  of  residents.  At  some  of 
the  institutions  there  is  a  manifest  difference  in  this  regard; 
in  others  none  is  apparent. 

"The  latter  would  seem  to  be  a  fatal  objection  to  this 
explanation,  but  a  moment's  consideration  will  show  that 
such  is  not  necessarily  the  case.  The  writer  from  personal 
observation  has  found  that,  although  the  nurses  and  attend- 
ants may  apparently  receive  the  same  food,  there  is,  never- 
theless, a  difference,  in  that  the  nurses  have  the  privilege — 
which  they  exercise — of  selecting  the  best  and  the  greatest 
variety  for  themselves.  Moreover,  it  must  not  be  over- 
looked that  nurses  and  attendants  have  opportunities  for 
supplementing  their  institutional  dietary  that  the  inmates, 
as  a  rule,  have  not. 

"In  this  connection  brief  reference  must  be  made  to  two 
other  epidemiological  features  of  pellagra.  It  is  universally 
agreed  (i)  that  this  disease  is  essentially  rural,  and  (2)  asso- 
ciated with  poverty.  Now  there  is  plenty  of  poverty  and 
all  its  concomitants  in  all  cities,  and  the  question  naturally 
arises  why  its  greater  predilection  for  rural  poverty?  What 
important  difference  is  there  between  the  elements  of  pov- 
erty in  our  slums  and  those  of  poverty  in  rural  dwellers? 
It  is  not  the  writer's  intention  to  enter  at  this  time  into 
a  detailed  discussion  of  these  questions;  he  wishes  to  point 


A  DISCUSSION  OF  THE  ETIOLOGY  OF  PELLAGRA       75 

out  one  difference  only.  The  difference  relates  to  the  diet- 
ary. Studies  of  urban  and  rural  dietaries  have  shown  that, 
on  the  whole,  the  very  poor  of  cities  have  a  more  varied  diet 
than  the  poor  in  rural  sections. 

"With  regard  to  the  question  of  just  what  in  the  dietary 
is  responsible,  the  writer  has  no  opinion  to  express.  From 
a  study  of  certain  institutional  dietaries,  however,  he  has 
gained  the  impression  that  vegetables  and  cereals  form  a 
much  greater  proportion  in  them  than  they  do  in  the  diet- 
aries of  well-to-do  people;  that  is,  people  who  are  not,  as  a 
class,  subject  to  pellagra. 

''The  writer  is  satisfied  that  the  consumption  of  corn  or 
corn  products  is  not  essential  to  the  production  of  pellagra, 
but  this  does  not  mean  that  corn,  the  best  of  corn,  or  com 
products,  however  nutritious  and  however  high  in  caloric 
value  they  may  be,  are  not  objectionable  when  forming  of 
themselves  or  in  combination  with  other  cereals  and  with 
vegetables  a  large  part  of  the  diet  of  the  individual. 

'Tn  view  of  the  great  uncertainty  that  exists  as  to  the 
true  cause  of  pellagra,  it  may  not  be  amiss  to  suggest  that 
pending  the  final  solution  of  this  problem  it  may  be  well  to 
attempt  to  prevent  the  disease  by  improving  the  dietary 
of  those  among  whom  it  seems  most  prevalent.  In  this 
direction  I  would  urge  the  reduction  in  cereals,  vegetables, 
and  canned  foods  that  enter  to  so  large  an  extent  into  the 
dietary  of  many  of  the  people  in  the  South,  and  an  increase 
in  the  fresh  animal  food  component,  such  as  fresh  meat, 
eggs,  and  milk." 

The  etiology  of  pellagra  is  yet  unproved,  though  the  reader 
should  remember  that  the  time  is  not  yet  ripe  to  cast  aside 
as  worthless  the  tomes  of  written  evidence  gathered  through 


76  PELLAGRA 

nearly  two  centuries  by  Italian  and  French  investigators, 
and  now  being  augmented  by  scores  of  able  research  workers 
on  both  sides  of  the  water. 

The  writer  has  not  cast  to  the  winds  the  "Zeist"  theory, 
though  agreeing  in  the  main  with  the  conclusions  of  Dr. 
Goldberger.  He  has  endeavored,  however,  to  give  every 
side  of  the  vexed  question,  permitting  the  reader  to  form  his 
own  conclusions. 

Lombroso  said:  ''In  pellagra^  then,  we  are  dealing  with  an 
intoxication  produced  by  poisons  developed  in  spoiled  corn 
through  the  action  of  certain  micro-organisms  in  themselves 
harmless  to  man.'' 

If  to  Lombroso's  dictum  of  spoiled  com  we  add  spoiled 
carbohydrates,  the  statement  will  come  near  embracing  our 
latest  and  most  reasonable  theories  as  to  the  causation  of 
pellagra. 


CHAPTER  IV 

SYMPTOMATOLOGY   AND    CLINICAL   COURSE    OF 
PELLAGRA 

Seldom  in  the  history  of  diseased  processes  has  there 
been  studied  one  whose  symptoms  and  cHnical  history 
presented  such  a  varied  panorama  as  pellagra. 

Its  many  characteristics  have  placed  it  in  quite  a  num- 
ber of  categories  covered  by  specialties  in  the  different 
fields  of  medical  endeavor.  The  gastro-enterologists  have 
dwelt  on  the  ever-present  digestive  disturbances,  often 
the  first  noticeable  manifestations  of  illness,  the  anorexia, 
the  epigastric  discomfort,  the  diarrhea,  and  all  that  train 
of  gastro-intestinal  ills. 

The  dermatologists  have  noted  the  skin  lesions,  be- 
ginning with  the  simple  erythema,  and  developing  the 
various  grades  of  dermal  inflammation.  Their  contention 
has  had  the  weight  of  "  external  evidence,"  for  few  cases 
of  pellagra  have  there  been  who  did  not  at  some  stage  show 
an  eruption  of  some  sort. 

The  neurologists  and  alienists  have  found  in  pellagra 
a  fertile  field  for  research  and  discussion.  The  nervous 
and  mental  symptoms  cover  a  range  extending  from  un- 
defined irritabiUty  and  change  of  disposition  to  dementia  or 
acute  mania;  exhibiting  abnormalities  resulting  from  simple 
lack  of  poise  up  to  organic  nerve  degenerations  of  fatal 

proportions. 

77 


78  PELLAGRA 

The  surgeons,  too,  have  figured  in  pellagra,  for  transfusion 
of  blood  from  healed  pellagrins  or  healthy  donors  has  ex- 
cited wide  comment,  and  at  one  time  seemed  to  promise 
a  therapeutic  solution.  Even  cecostomy  and  appendi- 
costomy  have  been  advocated  for  the  toxemia,  though  few 
pellagrins  have  consented  to  such  an  ordeal,  seeming  to 
prefer  the  ills  they  have  rather  than  fly  to  those  they  know 
not  of. 

To  attempt  to  follow  the  course  of  pellagra  from  one 
viewpoint,  or  to  permit  it  to  be  narrowly  classed  as  a  mani- 
festation of  one  organ  or  set  of  organs,  would  be  erroneous. 
It  would  be  unjust  to  the  patient,  unfair  to  the  honest 
student,  and  productive  of  endless  confusion. 

In  addition,  pellagra  does  not  always  appear  in  the  same 
form.  There  are  variations,  brought  about  by  age,  race, 
occupation,  previous  state  of  health,  previous  habits, 
environment,  heredity,  diet,  recurrence  of  the  disease,  and 
a  host  of  other  modifying  circumstances,  that  have  to  be 
taken  into  account  in  making  up  an  estimate  of  the  true 
nature  and  progress  of  this  malady. 

Again,  there  are  other  features  which  must  not  be  taken 
into  account  in  the  clinical  study,  as  types,  being  classified 
by  Lombroso  as  the  cerebral,  the  gastric,  the  florid  and 
others — some  of  these  classes  appearing  rather  unscientific 
for  such  an  authority.  The  division,  as  suggested  by 
some,  into  herpetic  or  erythematous,  nervous  or  digestive, 
may  be  set  aside  as  misleading,  because  these  symptoms 
may  appear,  and  frequently  do,  simultaneously. 

The  elder  Strambio,  to  whom  reference  has  been  made, 
divided  pellagra  into  three  types — the  intermittent,  or 
that  appearing  at  intervals,  between  which  the  patient 


Typic  pellagrous  erythema  of  hands  and  wrists.     (Courtesy  of  Dr. 
Watson,  Columbia,  S.  C.) 


J-  J. 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA        79 

seemed  perfectly  well;  the  remittent,  in  which  the  dis- 
ease was  better  at  certain  seasons,  though  not  entirely  well ; 
and  the  continuous,  where  no  improvement  took  place  at 
any  time,  but  the  illness  progressed  uninterruptedly  to  a 
fatal  issue. 

In  Italy,  among  the  rural  population,  there  are  seven 
kinds  commonly  spoken  of:  (i)  Those  who  go  mad;  (2) 
those  who  are  drawn  to  water;  (3)  those  who  go  backward; 
(4)  those  who  are  doubled  up;  (5)  those  who  become 
giddy;  (6)  those  who  are  always  hungry;  (7)  those  whose 
skin  peels. 

Roussel,  the  most  renowned  French  authority,  has  to  an 
extent  followed  Strambio's  classification,  only  he  has  made 
out  a  more  logical  case.  His  division  is  in  three  degrees 
primarily,  and  several  others  secondarily. 

His  pellagra  of  the  first  degree  corresponds  to  the  in- 
termittent form  of  Strambio,  only  he  subdivides  this  into 
commencing  pellagra  and  confirmed  pellagra. 

His  second  degree,  he  calls  paralytic  pellagra,  conform- 
ing to  the  remittent  form  of  Strambio. 

Roussel's  third  degree  is  denominated  pellagrous  cachexia, 
subdivided  into  that  with  the  eruption,  or  a  form  without 
any  eruption,  being  his  idea  of  a  pseudopellagra,  or  a 
cachexia  dependent  upon  some  degenerative  or  somatic 
stigmata. 

The  division,  as  made  by  some,  into  commencing  or 
confirmed  pellagra,  is  certainly  not  a  practical  one  clinically, 
for  some,  for  instance,  inveterate  alcoholics,  may  be  beyond 
successful  treatment  from  the  very  first  appearance  of  the 
disease;  while  other  pellagrins  assume  a  state  of  extreme 
chronicity,  never  becoming  seriously  ill  with  the  pellagra, 


8o  PELLAGRA 

and  always  apparently  amenable  for  a  time  to  favorable 
hygienic  surroundings  or  proper  medicinal  treatment. 

It  would  appear  to  the  writer  that  a  classification, 
somewhat  like  that  of  Babes  and  Sion,  is  preferable, 
though  even  their  classification  cannot  be  followed  in  its 
entirety. 

They  recognize  a  (i)  prodromal  stage,  or  pre-erythem- 
atous;  (2)  a  stage  in  which  there  are  erythema,  more  or 
less  gastro-intestinal  disturbances,  and  vague  symptoms 
of  peripheral  nervous  disquietude;  (3)  a  stage  of  deep  de- 
pression, bodily  and  mental,  with  accompanying  cachexia. 

The  simplest  classification  would  naturally  be  the  best, 
if  it  were  possible  to  adopt  such.  The  fact  is  patent,  how- 
ever, that  the  evolution  of  pellagra  from  one  stage  to 
another  cannot  always  be  followed;  that  the  original 
manifestations  may  be  either  cutaneous,  gastro-intestinal, 
or  nervous,  or  even  pscyhic;  that,  while  ordinarily  pellagra 
is  a  chronic  affection,  there  are  some  fulminant  cases,  where 
no  line  of  demarcation  can  be  noted  from  stage  to  stage; 
and  that  the  cachexia  may  come  on  early  or  late,  accord- 
ing to  the  patient's  power  of  resistance. 

As  emphasized  by  Dr.  Babcock,  it  is  well  to  recognize 
from  the  start  that  pellagra  is  a  trophoneurosis.  Neuras- 
thenic symptoms,  though  vague  and  nebulous,  are  often 
the  first  noticeable  changes,  and,  when  seen  with  the 
clearer  eye  of  retrospection,  are  often  as  plain  as  the 
noonday  sun. 

It  should  be  remembered  that  the  types  vary  in  different 
families  or  individuals.  That  it  varies  in  races,  or  those 
peoples  situated  far  apart,  has  already  been  allowed. 

In  some  the  gastro-intestinal  symptoms  predominate, 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA       8i 

the  patient  having  probably  inherited  poor  digestive  powers; 
in  others,  where  an  unstable  nervous  system,  made  more 
unstable,  perhaps,  by  faulty  habits,  predisposes  to  nervous 
manifestations,  such  may  predominate,  masking  every 
other  feature. 

That  seasonal  influence  may  affect  the  skin,  or  that 
some  cases  may  be  apparently  confined  to  cutaneous  lesions 
alone,  has  been  observed. 

At  present  the  writer  has  under  treatment  a  young 
girl  of  sixteen,  who  has  undoubtedly  the  erythema  of 
pellagra,  and  yet  has  never  had  a  single  qualm  of  any 
other  bodily  disturbance  produced  by  her  ailment,  and 
she  claims  to  be  not  the  least  ill. 

Sandwith  does  not  subscribe  to  a  "  prodromal  period," 
but  considers  pellagra  to  have  an  incubative  period  of 
nine  to  twelve  months'  duration,  in  which  time  there  are 
undefined  feelings  of  ill-being. 

To  all  intents  and  purposes,  however,  the  writer  thinks 
it  well  to  admit  the  existence  of  a  real  prodromal  period, 
during  which  the  incipient  pellagrin  complains  of  malaise, 
languor,  neuralgias,  indefinite  pains,  anorexia,  occasional 
"  digestive  upsets,"  and  an  indescribable  sense  that  all  is 
not  well. 

This  may  last  for  several  years,  may  never  develop  into 
pellagra,  or  may  merge  into  a  typical  case.  One  can 
never  tell. 

Dr.  H.  F.  Harris  goes  so  far  as  to  say  that  a  majority  of 
the  people  of  the  South  to-day  are  suffering  from  one  form 
or  another  of  "  corn-bread  poison,"  as  he  terms  it;  that 
numberless  cases  of  indigestion  that  eventually  recover; 
that  many  unrecognized  cachexias  eventually  clearing  up; 


82  PELLAGRA 

that  hundreds  of  so-called  auto-intoxications  are  in  reahty 
manifestations  of  "  corn-bread  poison." 

This  extreme  view  may  not  be  accepted  in  its  entirety, 
but  there  is  more  than  a  modicum  of  truth  in  his  asser- 
tion. This  he  has  proved  in  some  instances  by  the  quick 
gain  in  health  after  all  corn  products  have  been  eliminated 
from  the  dietaries  of  some  of  these  sufferers  from  obscure 
complaints. 

Parenthetically,  in  this  connection,  it  might  be  well  to 
caution  the  reader  to  be  on  the  qui  vive  in  all  cases  of 
atypical  digestive  disturbances,  lest  later  on  pellagrous 
symptoms  supervene,  to  the  chagrin  of  the  medical  attend- 
ant. 

Another  source  of  error  abides  in  those  who  have  for 
long  periods  of  time  suffered  with  chronic  indigestion, 
either  functional  or  organic.  During  this  long-drawn-out 
time  these  individuals  have  become  so  accustomed  to  their 
epigastric  and  abdominal  discomforts  that  they  ascribe 
all  their  ills  to  the  "  old  case  of  indigestion,"  and  fail  to 
recognize  the  advent  of  a  new  factor  in  the  pathologic 
drama. 

The  writer  has  records  of  pellagrins  with  concurrent 
chronic  gastritis  of  long  standing,  of  obstinate  hyperchlor- 
hydria,  of  gastric  and  duodenal  ulcer,  of  achyHa  gastrica 
(quite  frequent),  of  cholangeitis  and  cholecystitis,  of  con- 
firmed constipation  with  its  train  of  accompanying  tox- 
emias, and  a  few  have  been,  as  they  say,  "Hfe-long  dys- 
peptics." 

Gastric  Symptoms. — The  gastric  symptoms  of  pellagra 
do  not  differ  materially  from  those  of  chronic  catarrhal 
gastritis,  mostly  of  the  hypo-  or  anacid  variety.     In  gastric 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA       83 

analyses  of  64  cases  of  undoubted  pellagra,  free  hydro- 
chlorid  acid  was  absent  in  18,  deficient  in  31,  excessive  in  12, 
and  normal  in  3.  There  was  an  excess  of  stomach  mucus 
in  41  of  these.  In  those  who  were  nauseated,  or  suffered 
from  frequent  vomiting,  bile  was  found  in  the  stomachs 
of  nearly  every  one.  The  test  for  occult  blood  was  positive 
in  4.  It  was  particularly  noted  that  the  gastric  secretions 
were  diminished  or  absent  in  most  of  the  cases  of  long  stand- 
ing, and  a  few,  where  those  juices  were  increased,  were 
rather  recent  cases  of  pellagra. 

Roussel  considered  the  anorexia,  nausea,  and  gast^c 
indigestion  as  only  complications,  while  he  thought  dry- 
ness of  the  esophagus,  with  dysphagia  and  pyrosis,  the 
first  true  pellagrous  symptoms.  This  fine-cut  distinction 
would  be  hard  to  put  in  practice. 

Frequently  the  first  train  of  ailments  that  brings  up  a 
suspicion  of  pellagra  is  a  sensation  of  burning  in  the  mouth 
and  stomach,  accompanied  by  vague  neurasthenic  fancies. 
Slight  paresthesias  and  formications  of  small  areas  are 
generally  also  present.  Upon  examination,  the  physician 
observes  a  diffuse  redness  of  the  buccal  mucosa,  some- 
times with  a  few  aphthous  spots.  This  redness  is  not  the 
bright  scarlet  of  scarlatina,  nor  is  it  the  angry  hue  of 
stomatitis  proper,  but  rather  a  decided  pink,  glistening  on 
the  mucous  membrane  and  imparting  to  the  lips  a  cherry 
red,  with  a  well-marked  line  of  demarcation  at  the  junc- 
ture of  the  skin. 

This  buccal  redness  may  increase,  merging  into  vesicles 
or  even  superficial  ulceration.  Aphthous  spots,  about  the 
mouth  and  on  the  tongue,  are  quite  common,  especially  on 
the  tip  of  the  tongue  and  in  the  different  sulci  behind 


84  PELLAGRA 

the  gums  and  near  the  fauces.  Where  plates  of  artificial 
teeth  are  worn,  the  surfaces  where  the  plates  come  in  con- 
tact are  nearly  always  sore  and  ulcerated. 

Another  point  which  has  not  been  dwelt  on  is  the  tend- 
ency for  the  corners  of  the  mouth  to  become  sore.  Num- 
bers of  sore  mouths  have  been  treated  by  the  writer,  where, 
after  all  the  other  lesions  were  healed,  the  comers  still 
remained  raw  and  irritated. 

During  j:his  period  of  stomatitis  and  glossitis  the  sali- 
vary glands  are  quite  active,  even  to  the  point  of  the  saHva 
flowing  involuntarily  from  the  mouth.  Some  observers 
have  claimed  the  saliva  was  acid,  but,  if  so,  it  has  not 
been  present  in  any  of  the  cases  seen  by  the  writer.  Pro- 
copiu  does  not  think  this  excessive  secretion  of  saliva, 
amoimting  to  ptyalism,  is  caused  by  the  buccal  irritation, 
but  by  the  action  of  the  toxins  upon  the  saHvary  glands 
or  the  central  nervous  system. 

The  appearance  of  the  tongue  in  pellagra  is  often  quite 
characteristic.  It  may  be  coated  centrally,  but  the  edges 
are  smooth  and  slick,  showing  a  surface  denuded  of  epi- 
theHum.  The  papillae,  while  pronounced  and  some- 
times injected,  show  no  special  diagnostic  points.  In 
recent  cases  only  the  extreme  tip  and  sides  show  this 
denuded  condition,  but  later  on  the  whole  tongue  may 
lose  its  epitheHum,  giving  it  a  peculiarly  bald  look,  some- 
times called  the  "  cardinal  tongue."  When  the  redness 
is  pronounced  the  tongue  may  be  exquisitely  sensitive 
and  sore,  but  often  a  semipallor  follows  the  loss  of  the 
epitheHum,  and  a  lack  of  feeling  almost  akin  to  anes- 
thesia supervenes. 

So  often  has  the  writer  heard  expressions  of  seK-con- 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA        85 

gratulation  over  supposed  improvement  of  a  sore  tongue, 
when  it  was  only  the  temporary  anesthesia  that  would 
be  followed  by  a  greater  soreness. 

This  peculiar  but  almost  constant  sore  tongue  seems 
plain  enough  now,  since  the  medical  profession  are  on  the 
lookout  for  pellagra,  but  in  the  years  gone  by  gave  rise 
to  various  and  sundry  diagnoses  that  would  seem  ridicu- 
lous, had  they  not  been  fraught  with  such  possible  serious 
consequences  to  the  bewildered  sufferers. 

"  Superficial  glossitis,"  "  chronic  glossitis,"  "  Egyptian 
scurvy,"  "  sprue,"  "  tobacco  tongue,"  and  a  host  of  other 
sobriquets  settled  nothing,  and  kept  both  the  patient  and 
physician  floundering  in  the  shallows  and  breakers  of  un- 
certainty. 

In  recalling  some  obstinate  sore  mouths  of  former  days, 
the  writer  is  confident  that  a  generous  percentage,  though 
attributed  to  "  spoiled  stomachs,"  to  auto-intoxication,  to 
chewing  strong  tobacco,  and  other  causes  too  numerous  to 
mention,  were  in  reality  the  manifestations  of  pellagra  that 
never  fully  materialized. 

At  this  early  stage  pellagrins  often  complain  of  shooting 
pains,  almost  equal  to  the  lightning  pains  of  tabes.  Several 
instances  of  this  sort  have  occurred,  where  incipient  loco- 
motor ataxia  was  more  than  suspected,  only  to  develop 
into  pellagra  later  on. 

We  are  informed  that  in  the  European  countries  April 
and  May  are  the  months  in  which  the  more  positive  symp- 
toms make  their  appearance.  This  is  true,  to  a  marked 
extent,  in  America  also,  but  May  and  June  seem  to  bring 
out  the  pellagrous  manifestations  rather  more  than  any 
other   months.     Dr.    Babcock's   opinion    that    September 


86  PELLAGRA 

and  October  are  unfavorable  months  has  not  been  veri- 
fied by  the  writer.  October,  instead  of  being  a  hard 
month  on  pellagra,  often  ushers  in  the  first  improvement; 
probably  on  account  of  the  beginning  of  cool  weather. 

Skin  Symptoms. — The  dermal  manifestations  will  be 
next  considered,  though  let  it  not  be  understood  that  they 
are  necessarily  the  first;  on  the  contrary,  they  sometimes 
do  not  appear  until  late  in  the  course  of  the  malady,  and 
in  exceptional  instances  accompany  the  closing  scene. 

The  first  eruption  begins  as  an  erythema,  not  unlike  a 
sunburn,  and,  as  it  generally  shows  on  the  exposed  parts 
of  the  body,  is  often  attributed  to  that  agent.  This 
erythema  usually  begins  in  the  spring  months,  because,  it 
is  thought,  the  actinic  rays  of  the  sun  are  then  specially 
strong. 

Though  this  skin  lesion  gave  pellagra  its  name,  it  should 
be  no  more  considered  a  purely  skin  disease  than  leprosy 
or  syphiHs. 

This  erythema,  when  first  noticed,  consists  of  a  redness, 
swellLQg,  and  tension  of  the  skin,  which  sometimes  per- 
sists only  a  short  time,  leaving  the  surface  where  it  ap- 
peared scaly  and  rough. 

One  of  the  most  characteristic  features  of  the  eruption 
is  its  symmetry.  A  skin  lesion  seen  on  one  hand  or  arm 
is  almost  sure  to  be  duplicated  on  the  other  hand  or  arm; 
or  one  showing  on  one  side  of  the  face  or  one  part  of  the 
body  is  equally  seen  on  the  corresponding  side  or  part. 
This  has  become  so  well  recognized  as  a  diagnostic  factor 
that  any  one  of  experience,  who  sees  a  "  one-sided  "  erup- 
tion, would  require  much  corroborative  evidence  of  other 
kinds  to  make  out  a  diagnosis  of  pellagra. 


^ 


Typic  pellagrous  erythema  of  hands.      (Courtesy  of  Dr.  J.  J.  Watson, 
Columbia,  S.  C.) 


Showing  scaling  epidermis  after  erythema  and  vesication.     Note  absence 
of  ulceration  of  newly  formed  skin.     (Case  from  Peoria  State  Hospital.) 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA       87 

Many  have  been  the  cases  diagnosed  as  eczema — that 
dermal  mantle  of  ignorance,  covering  so  many  diagnostic 
shortcomings.  The  name  eczema,  having  a  pseudoscien- 
tific  sound,  and  being  easily  remembered  by  those  whose 
dermatologic  phraseology  had  become  hazy,  was  generally 
applied  to  all  sorts  of  skin  eruptions,  and  little  more  thought 
of  it  until  other  bodily  symptoms  forced  a  more  thorough 
study  of  the  trouble. 

As  Dr.  Watson  says,  "  The  only  type  of  eczema  worth 
our  consideration  is  erythematous  eczema  when  it  affects 
the  hands  or  face.  In  this  condition  we  would  not  have 
the  tongue  or  digestive  phenomena  that  occur  in  pellagra; 
and  while  these  symptoms  may  be  very  mild,  a  history  of 
their  presence  can  be  obtained  if  the  patient  is  properly 
questioned.  There  are  many  points  of  difference  between 
the  erythema  of  pellagra  and  erythematous  eczema,  but 
the  most  important  one  is  the  line  of  demarcation  between 
the  erythematous  area  and  healthy  skin  in  pellagra,  where- 
as in  erythematous  eczema  there  is  no  line  of  demarcation, 
the  erythematous  area  merging  into  the  healthy  skin  al- 
most imperceptibly.  The  itching  in  eczema  is  marked, 
whereas  pellagrins,  if  complaining  at  all,  only  refer  to  the 
burning  of  the  skin  lesion;  it  never  itches.  Eczema  has 
not  the  tendency  to  assume  the  light  chocolate  color  that 
is  so  characteristic  of  pellagra.  In  erythematous  eczema, 
as  in  other  forms  of  eczema,  you  are  very  Hkely  to  find 
other  eczematous  lesions  on  the  body." 

The  sharp  line  of  demarcation  between  inflamed  and 
healthy  skin  is  also  ably  described  by  Dr.  Howard  Fox  in 
a  recent  paper.  He  said  in  part,  "  A  characteristic  feature 
of  the  skin  lesions,  fully  as  important  as  the  symmetry,  is 


88  PELLAGRA 

the  sharply  circumscribed  border  seen  most  frequently 
in  the  patches  upon  the  neck  and  hands.  Indeed,  the 
lesions  upon  the  neck,  forming  the  so-called  "  neck  band  " 
of  Casal,  are  absolutely  distinctive,  and  could  not  well  be 
confused  with  any  other  lesions  of  the  skin.  Several  illus- 
trations are  seen  in  Merk's  book  which  are  almost  perfect 
counterparts  of  some  cases  seen  in  the  South.  None  of 
these  cases  presented  sternal  prolongation  of  the  neck- 
band, the  so-called  '  appendix  fasciolea  '  of  Casal.  Most 
of  the  cases  were,  however,  in  women. 

"  A  striking  picture  was  also  presented  by  the  eruption 
on  the  backs  of  the  hands  and  wrists,  when  the  charac- 
teristic border  was  present.  In  many  cases  this  border  was 
seen  not  only  on  the  back,  but  also  upon  the  front  of  the 
wrists.  In  the  cases  in  which  the  eruption  was  disappear- 
ing, the  sharp  border  was  no  longer  visible." 

The  writer  is  glad  that  Dr.  Fox  brought  out  this  last 
point,  for  the  line  of  demarcation  being  sharply  cut  or 
fading  into  obscurity  often  tells  the  difference  between  an 
augmenting  or  a  declining  state  of  pellagrous  disease. 

To  continue  with  Dr.  Fox,  "  Comparatively  few  of  the 
cases  showed  lesions  upon  the  face.  In  one  case  there  were 
lesions  upon  the  neck  and  cheeks,  which  at  first  glance 
looked  much  like  a  burn  that  might  have  been  produced 
by  carbolic  acid.  Some  of  the  cases  presented  lesions 
upon  the  dorsal  surfaces  of  the  feet.  In  others,  the  lesions 
involved  the  greater  part  of  the  legs  and  resembled  an 
eczema.  Few  of  the  lesions  noted  upon  the  feet  pre- 
sented a  sharply  marked  border." 

Another  skin  lesion  sometimes  confounded  with  pellagra 
is    erythema   multiforme.      To  quote  Dr.  Watson,  "  Like 


lypic  cervical   involvement,   showing   well-marked   "  butterfly."     (Case 
from  Peoria  State  Hospital.) 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA       89 

pellagra,  the  lesions  are  symmetric,  most  frequent  upon 
the  extensor  surface  of  the  forearms,  hands,  legs,  and  feet; 
not  accompanied  by  marked  subjective  sensations.  It 
differs  from  pellagra  in  that  the  erythematous  lesions  are 
markedly  raised  and  the  skin  between  the  various  lesions 
is  of  normal  color." 

Dr.  Watson  mentions  six  cases  treated  for  poison  oak, 
and  the  writer  recalls  several.  This  error  could  have  been 
avoided  by  ascertaining  that  none  of  the  cases  had  been 
where  they  could  have  encountered  the  poisonous  plant, 
and  also  by  remembering  that  the  vesicles  first  occur  be- 
tween the  fingers,  and  extend  from  this  point,  and  that 
in  pellagra  there  are  not  often  seen  vesicles,  but  large  bullae. 

Quite  an  interesting  case  was  some  time  ago  reported 
to  the  writer,  in  which  a  young  man  in  South  Georgia, 
while  convalescing  from  pellagra,  and  after  the  erythema 
on  his  arm  was  nearly  faded,  came  in  contact  with  some 
poison  oak,  and  had  a  sharp  attack  of  irritation  on  his 
wrists  and  hands.  The  poison  oak  dermatitis  was  severe 
and  painful,  but  it  did  not  seem  to  have  the  least  in- 
fluence on  the  pellagrous  erythema.  After  the  dermatitis 
had  abated,  the  vesicles  had  disappeared,  and  all  itching 
had  ceased  the  characteristic  skin  lesion  of  pellagra  was 
still  in  evidence,  seeming  to  have  not  been  affected  at  all. 

Another  unique  case  was  reported  from  Florida,  where, 
during  an  outbreak  of  smallpox,  a  lady  with  a  disappear- 
ing pellagrous  erythema  decided  to  be  vaccinated.  Her 
vaccination  "  took  "  in  short  order,  and  for  several  days 
she  had  an  extremely  sore  arm,  the  inflamed  area  from  the 
vaccination  being  superimposed  over  the  original  red- 
dened surface.     She  also  had  fever,  general  aching,  and 


go  PELLAGRA 

all  the  uncomfortable  symptoms  of  a  vaccine  infection, 
but  the  course  of  the  pellagra  was  not  modified  in  the  least. 
Her  bowels,  which  were  inclined  to  diarrhea,  remained 
the  same,  and  some  evidences  she  showed  of  a  secondary 
pellagrous  neuritis  were  neither  mitigated  nor   deepened. 

Another  skin  lesion  mentioned  by  Dr.  Watson,  as  some- 
times mistaken  for  pellagra,  is  lupus  erythematosus.  This 
might  cause  some  confusion,  but  only  when  the  pellagrous 
erythema  attacked  the  face,  producing  the  characteristic 
lesion  across  the  nose;  this,  however,  is  practically  impos- 
sible without  the  hands  being  affected  at  the  same  time, 
which,  of  course,  would  at  least  arouse  the  suspicion  of 
pellagra,  and  a  search  for  stigmata  of  the  disease  would  be 
made,  and,  if  found,  would  dispel  any  doubt  that  might 
exist. 

Dr.  Howard  Fox,  in  his  article  entitled  "  Personal 
Observations  on  the  Skin  Symptoms  of  Pellagra,"  remarks, 
"  The  name  erythema,  by  which  the  eruption  of  peUagra 
is  generally  denoted,  does  not  appear  to  me  to  be  entirely 
appropriate.  It  would  seem  quite  proper  to  use  the  term 
erythema  for  the  first  stages  of  the  disease,  which  resembles 
an  ordinary  simburn  and  which  lasts  only  a  few  days.  But 
it  seems  somewhat  anomalous  to  speak  of  the  entire  erup- 
tion as  erythema,  when  the  erythematous  stage  is  so  com- 
paratively insignificant,  while  the  stage  of  desquamation 
is  so  characteristic  and  of  such  long  duration.  An  erup- 
tion which  is  called  an  erythema  conveys  the  idea  of  affec- 
tions such  as  erythema  multiforme  or  the  so-called  toxic 
erythemata,  which  are  not,  as  a  rule,  accompanied  by 
desquamation.  The  general  term  dermatitis  would  be  a 
more  appropriate  name,  in  my  opinion,  than  erythema  for 


Symmetric  erythema  and  pigmentation  in  pellagra.      (Courtesy  of  Dr. 
J.  W.  Babcock.) 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA       gi 

the  pellagrous  eruption.  This  dermatitis  particularly 
affects  the  back  of  the  hands,  the  lower  third  of  the  fore- 
arms, occasionally  also  the  dorsum  of  the  feet;  it  also 
appears  on  the  face,  neck,  and  upper  part  of  the  chest;  in 
fact,  on  the  places  that  are  uncovered  and  exposed  to  the 
sunlight.  In  the  case  of  persons  who,  while  laboring,  go 
almost  naked,  such  as  the  fellahs  in  Egypt,  the  greater 
part  of  the  body  is  affected." 

In  Roumania,  where  many  children  run  naked  about  the 
streets,  the  erythema  is  not  confined  so  much  to  the  locations 
on  the  body  mentioned,  but  are  much  more  widely  dissem- 
inated.    Such  has  also  been  reported  from  Rhodesia. 

Dr.  Babcock,  referring  to  instances  in  Algiers,  France, 
and  also  South  Carolina,  says,  "  Attention  has  been  di- 
rected to  a  dermatitis  occupying  the  whole  vulvar  region, 
as  well  as  the  perineal,  the  anal  fold,  and  the  internal  sur- 
faces of  the  thighs,  which  are  brought  in  contact  by  adduc- 
tion. Here  pressure,  as  was  noted  by  Sandwith,  is  clearly 
an  exciting  cause  of  the  inflammatory  eruption.  In  many 
of  our  cases  the  surface  of  the  elbows  and,  to  a  less  ex- 
tent, of  the  knees  is  involved  for  a  long  while.  There  is 
also  a  tendency  for  the  dermatitis  to  extend  from  the  el- 
bow down  the  ulnar,  sometimes  meeting  the  '  gauntlet ' 
coming  up  from  the  hand.  Here,  again,  pressure  is  a 
causative  factor." 

Scheube  remarks,  "  The  skin  becomes  red  and  swollen, 
causing  the  patient  to  experience  a  sensation  of  tension, 
itching,  or  burning.  Sometimes  little  blebs  and  pustules, 
that  dry  up  to  scabs,  develop.  After  the  erythema  has 
subsided  for  a  few  weeks,  a  desquamation  of  the  epidermis 
in  large  patches  takes  place." 


92  PELLAGRA 

The  vaginal  and  anal  irritation  has  been  frequently  seen 
by  the  writer,  and  has  constituted  a  most  painful  com- 
plication in  every  instance.  In  some  of  such  cases  the 
bowel  evacuations  were  watery,  acrid,  and  occasionally 
involuntary,  so  that  the  constant  flow  of  this  irritating 
fecal  discharge  over  the  inflamed  surface  gave  rise  to  ex- 
cruciating agony. 

This  inflammation  of  the  mucous  membrane  and  margins 
around  the  vulva  and  anus  occasionally  take  on  a  diph- 
theritic aspect,  edema  may  occur,  followed  by  buUae, 
pustules,  and,  in  rare  cases,  even  by  gangrene.  Such  are 
sometimes  called  the  "  wet  cases." 

It  is  probable  that  some  of  these  cases  were  diagnosed 
dermatitis  exfoKativa  in  the  United  States  some  years  ago. 

In  pellagrins  where  the  eruption  has  persisted  for  a 
long  time  it  tends  to  assume  a  dingy  black  hue,  rough  and 
hard,  and  exceedingly  disagreeable  to  the  sufferer.  These 
dark  patches  are  more  often  noticed  on  the  palms  of  the 
hands,  the  soles  of  the  feet,  on  the  sides  of  the  nose,  or  on 
the  forehead,  at  the  junction  of  the  eyebrows. 

When  the  pellagrous  eruption  begins  to  abate  it  first 
fades  by  degrees,  and,  if  not  too  deep,  desquamates  in  fine 
branny  scales,  leaving  a  bright  denuded  surface,  eventually 
becoming  normal.  During  this  time  exposure  to  the  sun's 
rays,  or  even  bright  Hght,  may  set  up  a  renewal  of  the 
erythema. 

The  deeper  forms  of  pellagrous  dermatitis  may  exfoUate 
in  large  scales,  leaving  raw,  bleeding  surfaces,  or  even  ul- 
cerated patches,  requiring  granulations  for  healing. 

The  very  deep  inflammations  of  the  skin,  where  extensive 
loss  of  tissue  and  gangrene  take  place,  are  rare,  generally 


S\mmelric  discoioraUon  of  both  forearms  in  pellagra. 

A.  Zeller.) 


(Case  of  Dr.  G. 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA        93 

marking  the  terminal  symptoms,  and  associated  with 
utter  failure  of  vital  resistance. 

The  skin  lesions  of  pellagra  are  many  and  varied,  but  the 
writer  feels  that  these  descriptions,  taken  in  connection  with 
the  illustrations  of  the  different  types,  should  enable  the 
reader  to  form  a  satisfactory  idea  of  their  appearance. 

Digestive  Symptoms. — Some  of  the  objective  findings 
of  the  stomach  conditions  have  been  previously  touched, 
but  the  general  digestive  disturbances  are  of  the  utmost 
import  and  deserve  careful  study. 

The  views  of  Babcock,  Roussel,  Procopiu,  and  Merk 
figure  largely,  correilated  with  the  personal  experience  of 
the  writer. 

One  of  the  first  symptoms  of  pellagra  is  an  undefined 
dyspepsia,  with  flatulence,  pyrosis,  eructations,  and  epigas- 
tralgia.  A  large  majority  of  pellagrins  are  dyspeptic, 
this  symptom  persisting  to  a  lesser  degree  during  remis- 
sions of  the  disease.  This  indigestion  may  remain  in 
evidence  for  several  years,  during  which  time  no  typic 
pellagrous  symptoms  may  appear,  and  this  has  occasioned 
Roussel's  term  "  pellagra  sine  pellagra."  He  said,  "  The 
expression  pellagra  sine  pellagra  can  only  be  applied  to  a 
temporary  absence  of  the  cutaneous  eruption,  either  at  the 
beginning  or  during  the  course  of  the  malady."  Strambio 
also  admitted  this  term,  though  he  stressed  the  caution  that 
no  positive  diagnosis  of  pellagra  should  be  made  when 
there  was  no  eruption,  unless  there  was  other  decided 
corroborative  evidence. 

The  epigastralgia  is  a  most  common,  sometimes  perplex- 
ing, symptom,  coming  on  at  irregular  intervals,  and  ap- 
parently bearing  no  relationship  to  the  amount  or  kind  of 


94  PELLAGRA 

food  ingested.  This  pain  has  a  slight  resemblance  to  the 
gastric  crisis  of  locomotor  ataxia,  but  should  be  easily- 
differentiated  if  proper  care  is  exercised. 

The  intense  burning  of  the  esophagus  and  stomach,  so 
often  in  evidence,  is  seldom  due  to  increased  hydrochloric 
acid,  for  that,  as  has  been  shown,  is  nearly  always  dimin- 
ished. This  burning  is  probably  analogous  to  the  burning 
of  the  tongue  and  mouth,  and  to  that  in  other  parts  of  the 
body,  to  be  mentioned  later. 

It  should  not  be  forgotten  that  pellagra  can  be  en- 
grafted on  to  any  of  the  functional  or  organic  gastric  affec- 
tions, and  may  compKcate  the  picture,  early  or  late,  in  the 
course  of  the  disease. 

Periods  of  anorexia,  interspersed  with  happier  periods 
of  normal  appetite,  even  bulimia,  are  among  the  early 
S3nDaptoms.  It  is  not  uncommon,  however,  for  the  patient 
to  suffer  with  akoria,  or  the  sense  of  increased  satiety, 
where  he  feels  a  craving  for  food,  but  finds  himself  imable 
to  eat  but  a  few  mouthfuls  before  feeling  as  if  an  over- 
whelming meal  has  been  consumed.  Occasionally,  on 
accoimt  of  the  epigastralgia,  the  sufferer  fears  that  differ- 
ent articles  of  food  disagree,  until  there  is  developed  a 
sitophobia,  or  morbid  fear  of  food,  which  may  lead  to 
dangerous  inanition  unless  corrected.  This  last-named 
symptom  is  usually  found  in  cases  where  nerv^ous  or  psychic 
S)rmptoms  predominate. 

Vomiting  is  seldom  present,  and  not  infrequently  pa- 
tients clamor  for  solid  food  when  they  know  full  well  that 
they  cannot  digest  nor  assimilate  it.  Records  of  over  200 
cases,  searched  with  regard  to  vomiting,  show  it  present 
in  less  than  20. 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA       95 

Gastric  flatulence  is  extremely  frequent,  accompanied 
by  loud  and  explosive  eructations.  A  few  patients  in  the 
early  stages  of  pellagrous  indigestion  have  been  known  to 
acquire  the  habit  of  aerophagia,  leading  to  constant  and 
disconcerting  eructations,  which  bore  no  relation  to  the 
food  eaten. 

The  sense  of  epigastric  weight  after  meals,  mainly  in 
those  pellagrins  with  previous  gastric  catarrhs,  is  often 
noted.  They  complain  bitterly  of  this,  sometimes  walk- 
ing partly  doubled  up  in  the  hope  of  temporary  relief. 

The  few  cases  of  duodenal  ulcer  complicating  pellagra 
have  shown  all  the  clinical  symptoms  of  that  entity  plus 
those  of  the  pellagra.  The  same  may  be  said  concerning 
the  cases  of  peptic  ulcer. 

Flatulence  is  also  frequently  observed  in  the  small 
intestine,  occasioning  abdominal  discomfort,  borborygmi, 
and  colicky  pains.  Very  often  increased  peristalsis  is  set 
up  soon  after  each  meal. 

In  one  instance  the  writer  had  the  opportunity  of  ex- 
amining the  duodenal  contents  of  a  pellagrin.  The  con- 
tents were  obtained  by  the  Einhom  duodenal  bucket, 
which  was  withdrawn  ten  hours  after  swallowing.  The 
contents  were  a  golden  yellow,  thick  and  turbid,  and 
showing  no  reaction  for  trypsin.  This,  of  course,  proves 
nothing,  being  mentioned  only  as  a  matter  of  interest. 

Occasionally  constipation  is  found  in  the  earlier  stages 
of  pellagra,  but  this  is  exceptional.  The  few  instances 
coming  under  the  writer's  notice  were  chronically  con- 
stipated long  before  the  advent  of  the  pellagra.  A  case 
of  pellagra,  where  constipation  persists,  may  be  classed 
as  a  decided  rarity. 


96  PELLAGRA 

The  usual  rule  is  to  get  a  history  of  attacks  of  diarrhea, 
apparently  causeless,  not  depending  on  what  is  eaten,  and 
ceasing  suddenly.  This  diarrhea  is  believed  by  Babes  to  be 
due  to  irritation  of  the  sympathetic  ganglia  and  the  plexus 
of  Auerbach.  This  view  has  only  recently  been  accepted 
by  American  observers,  for  two  years  ago,  when  the  writer 
contended  that  the  first  diarrheal  manifestations  were  of 
central  origin  and  compensatory^  in  character,  his  views  were 
acquiesced  in  by  only  a  few  students  of  pellagra, 

Strambio  distinguished  two  kinds  of  diarrhea,  the  one 
a  dysentery  characterized  by  frequent  colicky  and  muco- 
sanguinolent  stools ;  the  other  more  common,  and  character- 
ized by  watery  discharges,  frequent,  and  hard  to  control. 
According  to  him  the  dysenteric  is  more  common  in  the 
earlier  stage,  but  the  serous  or  aqueous  diarrhea  belongs 
to  the  later  and  progressive  stage,  and  is  an  important 
factor  in  producing  the  cachexia. 

According  to  the  experience  and  observation  of  the 
writer,  this  early  diarrhea  is  often  very  watery,  explosively 
ejected,  and  hard  for  the  patient  to  control.  This  tendency 
to  lose  control  of  the  anal  sphincters  soon  after  the  advent 
of  the  first  diarrhea  has,  so  far  as  observed,  been  particu- 
larly noticed. 

A  recent  case  of  this  sort  was  a  young  widow,  whose 
greatest  complaint  was  her  lack  of  control  of  her  bowels, 
causing  frequent  soiling  of  her  linen.  At  present  she  is 
better  in  many  ways,  but  stiU  reports  difficulty  in  manag- 
ing her  sphincters. 

The  odor  of  these  pellagrous  stools  is  almost  character- 
istic. To  describe  an  odor  is  at  the  best  unsatisfactory, 
but,  like  that  exhaled  from  smallpox  patients  in  the  des- 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA       97 

quamative  stage,  or  the  peculiar  smell  of  the  vaginal 
discharges  in  uterine  carcinoma,  these  feces  have  a  dis- 
tinctive odor.  The  feces  are  usually  dark,  often  very- 
watery,  irritating  to  the  parts  over  which  they  pass,  and 
full  of  frothy  bubbles  of  gas. 

Several  who  have  seen  many  cases  of  pellagra,  and  had 
occasion  to  often  smell  these  foul  stools,  have  expressed 
the  belief  that  they  could  diagnose  pellagra  fairly  well 
from  the  oKactory  senses  alone.  In  this  somewhat  bizarre 
statement  the  writer  is  tempted  to  concur. 

The  diarrhea,  of  central  origin  and  compensatory  at  first, 
becomes  eventually  inflammatory  in  nature,  partaking  of 
all  the  sjnnptoms  of  irritative  diarrhea  or  ordinary  dysen- 
tery. When  this  condition  arrives,  it  is  no  longer  com- 
pensatory or  salutory  in  its  effect,  but  rapidly  saps  the 
strength  and  reduces  the  weight.  It  is  not  uncommon  to 
see  a  patient  lose  five  to  ten  pounds  in  a  week  from  such  a 
cause.  The  diarrhea  may  even  become  choleraic,  draining 
the  body  of  its  fluid  in  short  order. 

Should  the  disease  progress  favorably,  and  the  patient 
seem  convalescent,  the  whole  digestive  system  remains 
below  par  for  long  after.  The  appetite  is  finical,  the 
stomach  easily  upset,  flatulence  often  in  evidence;  while 
the  slightest  indiscretion  in  either  eating  or  otherwise  is 
sure  to  result  in  a  renewal  of  the  diarrhea. 

Can  it  be  wondered  that  so  many  healed  pellagrins  be- 
come confirmed  "  nervous  dyspeptics,"  afraid  to  eat  a 
sufficiency  for  daily  calories,  and  at  all  times  sitophobic 
to  a  degree? 

Before  leaving  the  alimentary  tract  it  might  be  well  to 
mention  that  when  patients  complain  of  hemorrhoids,  as 


98  PELLAGRA 

they  frequently  do,  an  investigation  will  reveal  a  proc- 
titis, which  will  explain  some  of  their  "  bearing-down  " 
pains,  and  whose  relief  will  greatly  ameHorate  the  general 
condition. 

It  is  the  opinion  of  many  that  the  digestive  symptoms  of 
pellagra  in  the  United  States  run  a  more  severe  course 
than  in  Europe,  especially  in  Italy.  An  idea  prevailing 
in  some  quarters  is  that  in  those  countries  there  has  been 
acquired,  either  through  heredity  or  some  other  manner,  a 
gradual  immunity,  which  has  rendered  the  pellagrous 
toxin  less  able  to  make  the  rapid  inroads  observed  in  a 
newer  soil  for  its  invasion. 

So  much  for  the  gastro-intestinal  disorders  of  pellagra. 

Nervous  Phenomena. — Before  entering  into  the  psychic 
manifestations  of  this  malady  the  more  strictly  nervous 
symptoms  will  be  considered,  though  it  will  be  impossible 
to  keep  the  nervous  and  psychic  separate  at  all  times. 

As  has  been  admitted,  many  of  the  expressions  are  those 
of  a  trophoneurosis,  and  can  be  explained  in  no  other  way. 
The  many  pains,  the  burning  surfaces,  the  quick  and  sur- 
prising changes  in  the  aspect  of  pellagra  from  day  to  day, 
are  necessarily  the  result  of  certain  neuroses,  some  of  them 
understood,  some  still  obscure. 

From  the  first  fleeting  pains,  accompanied  often  by 
paresthesias  and  formication,  to  the  flickering  pangs  of  a 
disappearing  neuritis,  the  last  sign  of  the  disease,  nervous 
symptoms  are  in  evidence  practically  the  entire  time. 

One  of  the  very  first  indications  is  a  dysphagia,  coming 
on  intermittently  and  disappearing  without  reason.  The 
patient  naturally  cannot  understand  such  a  phenomenon, 
comes  to  the  physician  for  advice,  and  is  surprised  to  find 


This  case  shows  a  marked  and  extensive  dermatitis  over  back  and  front 
of  neck,  face,  forearms,  hands,  legs,  and  feet.  Was  transfused  from  sister, 
who  had  never  had  pellagra.  Marked  improvement  for  eight  days.  Died 
suddenly  at  night  from  perforation  of  intestinal  ulcer.  (Courtesy  of  Dr. 
H.  P.  Cole,  Mobile,  Ala.) 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA       99 

that  the  dysphagia  has  disappeared.  It  is  then  thought 
to  be  an  hysteric  manifestation,  until  other  indications  of 
pellagra  are  felt. 

Early  tremors  are  not  rare,  appearing  somewhat  like 
the  tremors  of  disseminated  sclerosis.  These  tremors  are 
more  marked  in  the  hands  than  elsewhere,  though  the 
tongue  is  often  affected.  Frequently  the  patient  is  unable 
to  stand  with  the  eyes  closed,  swaying  almost  as  much  as 
in  tabes. 

An  instance  of  this  sort  was  under  the  care  of  the  writer 
several  months  ago.  The  patient,  a  young  lady  of  good 
circumstances  and  breeding,  first  noted  the  tremors  on 
attempting  to  pass  food  on  the  table  to  other  members  of 
the  family.  These  tremors  in  a  short  while  began  to  affect 
her  tongue,  making  her  speech  halting  and  uncertain. 
She  found  that  she  walked  in  the  dark  with  difficulty  and 
was  timorous  about  walking  alone.  Her  family  physician, 
a  gentleman  of  intelligence,  thought  it  a  beginning  neuras- 
thenia brought  on  by  a  period  of  religious  excitement  ex- 
perienced at  a  series  of  services,  which  were  led  by  an 
evangelist  of  the  superstrenuous  sort. 

Soon  after,  she  noted  an  intermittent  diarrhea  and  in- 
digestion, and  in  a  few  months  the  erythema  confirmed  the 
diagnosis  already  suspected.  After  a  serious  illness,  in 
which  nervous  and  psychic  symptoms  predominated,  im- 
provement set  in,  and  she  seems  convalescent  at  this  time. 

Contractures  are  generally  late  symptoms  and  of  grave 
prognostic  import.  The  writer  has  not  observed  many, 
but  others  have  met  with  contractures  quite  often  in  vary- 
ing degrees  of  severity.  These  patients  move  with  diffi- 
culty, are  averse  to  any  change  of  position,  and  sometimes, 


loo  PELLAGRA 

in  their  eflforts  to  find  a  comfortable  pose,  assume  grotesque 
attitudes  that  would  provoke  laughter  were  the  patient's 
condition  not  one  of  such  misery. 
A  most  remarkable  case  of  this  sort  is  narrated  by  Marie : 
"  In  the  case  of  one  woman  the  skin  was  cadaverous  and 
covered  with  telangiectases,  the  chestnut-brown  hair  scat- 
tered over  with  white  and  reddish  spots,  a  rude  beard, 
cranium  ultrabrachycephahc,  nose  flat,  teeth  of  the  upper 
jaw  worn  away  by  constant  friction,  and,  from  this  cause 
doubtless,  a  varicose  nodule  had  formed  on  the  tip  of  the 
tongue;  emotional  reaction  was  feeble,  but  not  abolished; 
tactile  and  painful  sensibility  was  much  diminished;  she 
was  resistant;  mentally  she  presented  the  picture  of  de- 
mentia precox  of  the  depressed  type  and  was  mute;  hid 
herself  in  fear  in  the  most  retired  comers  of  the  room  or 
yard;  if  any  one  succeeded  in  making  her  talk,  she  did  not 
seem  to  be  deluded,  but  begged  others  about  her  to  have  pity 
oij  her  misery,  and  was  grateful  for  attentions  received,  of 
which  she  thought  herself  unworthy.  All  her  inclinations 
and  all  her  psychic  activity  expressed  themselves  in  the 
most  extreme  muscular  contractions.  She  sought  the 
most  favorable  positions  for  contortions  while  hanging 
to  slats  and  bars,  to  which  she  clung  even  with  her  teeth, 
her  tongue,  and  toes.  She  gave  as  an  explanation  that 
she  could  not  do  otherwise.  These  symptoms  continued 
up  to  her  death,  from  tuberculosis,  although  in  the  last  few 
days  she  uttered  monosyllables — '  good,  bad,  your  kind- 
ness, so  much  misery,'  etc.  But  up  to  the  last  day  she 
continued  to  conceal  herself  as  much  as  possible  under 
the  cover,  and  to  cling  with  her  feet  to  the  bars  of  the  bed." 
We  are  informed  by  Itahan  writers   that  in  some  in- 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA      loi 

stances  laborers  seem  to  feel  a  greater  strength  than  usual 
when  first  attacked  by  pellagra.  Such  has  not  been  ob- 
served in  this  country,  but,  on  the  contrary,  weakness  and 
uncertainty  of  the  lower  limbs  are  frequently  noted  among 
the  first  symptoms.  There  may  be  even  pareses,  though 
Tonnini,  a  contemporaneous  Italian  observer,  claims  that 
pellagrous  paresis  never  attacks  the  muscles  of  respiration 
or  those  of  the  face  alone. 

Among  other  neuroses  are  muscular  spasms,  tetanic 
convulsions,  epileptiform  seizures,  and  sudden  attacks  of 
vertigo.  Some  of  these  muscular  spasms  produce  very 
erratic  movements,  giving  rise  to  some  of  the  queer  classi- 
fications bestowed  upon  the  disease  by  uneducated  people. 
These  sufferers,  during  such  attacks,  fall  backward  or 
sidewise,  or  jerk  in  choreic  fashion.  These  attacks  are 
precipitated  or  made  worse  by  external  sensory  impres- 
sions, such  as  loud  talking,  slamming  of  doors,  etc. 

Practically  all  pellagrins  possess  exaggerated  reflexes,  the 
normal  or  diminished  reflexes  being  in  a  decided  minority. 
Sometimes,  though  not  often,  there  is  a  difference  in  the 
two  sides,  or  ankle  clonus  is  wanting. 

The  skin  reflexes  are  generally  either  increased  or  de- 
creased, seldom  normal.  When  increased,  the  mechan- 
ical irritability  of  the  muscles  is  in  most  cases  also  in- 
creased. 

The  electric  reactions  of  the  muscles  and  nerves  have 
been  studied  by  Roncoroni  in  the  hospital  of  Turin.  These 
experiments  were  made  on  four  pellagrins,  three  of  whom 
were  in  good  physical  condition.  They  did  not  display 
the  reaction  of  degeneration  and  did  not  show  any  devia- 
tion, either  quantitative  or  qualitative,  from  the  normal. 


I02  PELLAGRA 

In  one  case  excitability  was  notably  less  than  in  the  others, 
which  was  probably  due  to  profound  denutrition.  This 
is  not  without  interest  for  differential  diagnosis  from 
polyneuritis,  progressive  muscular  atrophy,  lateral  amyo- 
trophic sclerosis,  transverse  myehtis,  and  other  diseases. 
He  also  found  a  greater  faradic  excitabiHty  of  the  flexors. 
According  to  him,  diminution  of  the  faradic  excitabiHty, 
even  in  the  cases  of  spastic  rigidity,  is  found  in  the  third 
period  of  pellagra;  under  certain  circumstances  this  reac- 
tion might  serve  as  a  differential  diagnostic  sign  from, 
spastic  spinal  paralysis. 

In  the  majority  of  pellagrins,  however,  unless  there  are 
marked  nervous  symptoms,  the  ordinary  gait  is  not  mate- 
rially changed. 

Wamock  says,  "  There  is  no  special  gait  in  early  cases, 
but  when  the  disease  has  become  advanced  the  patient 
walks  with  the  legs  weU  apart,  the  shoulders  raised  and 
bent  forward,  and  when  he  has  reached  the  penultimate 
stage  he  cannot  take  more  than  a  few  short  feeble  steps 
without  falling  down,  while  in  the  last  stage  of  aU  the 
patients  are  unable  ito  stand  up  or  even  raise  themselves 
up  in  bed,  and  this  paresis  is  sometimes  accompanied  by 
tremors  of  the  limbs." 

In  the  last  stages,  of  course,  the  reflexes  are  all  abol- 
ished. 

The  sensibflity  to  touch  and  pain  is  in  most  cases  of 
pellagra  diminished,  with  the  frequent  exception  of  the  area 
over  the  epigastrium  and  abdomen.  "  Out  of  30  severe 
cases,  Tonnini  found  five  times  a  profoimd  analgesia  ex- 
tending from  the  feet  even  to  the  face,  but  greater  in  the 
lower  extremities;  he  found  more  or  less  analgesia  fourteen 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA      103 

times  and  hyperalgesia  four  times.  In  40  pellagrins  less 
severely  affected  he  found  two-thirds  analgesic  and  only 
two  hyperalgesic." 

"  Hyperalgesia  in  pellagra  is  more  common  in  florid  types, 
and  is  accompanied  by  a  decided  elevation  of  temperature. 
The  cases  are  numerous  in  which  if  they  are  touched,  prin- 
cipally on  the  stomach  or  on  the  thorax,  they  begin  to  cry 
out,  and  at  the  least  noise  they  start;  others  have  painful 
paresthesias,  as  if  water  were  thrown  on  their  heads,  or  as 
if  they  were  pricked  on  the  legs  by  thousands  of  pins; 
they  complain  also  of  burning  in  the  eyes,  in  the  nose,  and 
in  the  face.  Insensibility  to  pain  is  often  shown  by  their 
voluntary  exposure  to  cold,  as  well  as  to  burning  or  scorch- 
ing, to  which  they  repeatedly  expose  themselves.  Tonnini 
found  the  sensibility  to  heat  better  preserved  in  the  face  than 
in  the  extremities,  but  sometimes  cryesthesia  is  found." 

These  abnormal  sensations  of  the  skin  and  other  parts  of 
the  anatomy,  these  aching  pains  and  burning  sensations, 
have  been  the  bane  of  many  of  the  pellagrins  under  the 
observation  of  the  writer.  In  a  number  of  instances,  after 
seeing  the  patients  safely  through  the  gastro-intestinal  dis- 
turbance, the  eruption  and  the  weakness,  the  manifesta- 
tions of  neuritis  were  so  severe  and  obstinate  that  they  have 
broken  away,  going  from  one  medical  advisor  to  another 
in  frantic  efforts  to  obtain  relief.  These  are  the  invalids 
who  readily  become  a  prey  to  charlatans  and  quacks  and 
all  that  ilk,  who,  by  specious  and  misleading  representa- 
tions, extort  "  blood  money  "  from  these  poor  desperate 
sufferers. 

The  daily  papers  have  recently  carried  advertisements  of 
a  vaunted  "  pellagra  cure,"  where  a  tiny  bottle  was  sold  for 


I04  PELLAGRA 

an  unreasonable  price,  and  where  a  guarantee  to  cure  was 
included.  To  bolster  up  these  ridiculous  claims  were 
printed  letters  from  supposed  pellagrins,  claiming  to  be 
cured  in  from  ten  to  fifteen  days — God  save  the  mark! 

Cephalalgia  of  the  severest  sort  is  not  uncommon.  With 
the  headache  is  ringing  in  the  ears  and  dizziness.  Dr. 
L.  C.  Allen  mentions  a  patient  of  his,  a  fine  old  gentleman, 
who  would  often  say,  "I'm  drunk,  doctor,  I'm  drunk; 
I  have  not  drank  anything,  but  I'm  drunk."  He  would 
often  fall  down  and  bruise  his  head.     He  died  soon  after. 

With  the  exception  of  an  occasional  explosion  of  erotic 
passion  during  the  incipiency,  the  sexual  desire  is  either 
diminished  or  abolished  in  pellagra.  This  the  writer  has 
noted  quite  a  number  of  times,  and  it  does  not  seem  to 
be  mentioned  specially  in  contemporary  literature.  In  one 
instance,  a  middle-aged  man  consulted  a  specialist  in 
Atlanta  for  impotence,  not  considering  the  concurrent 
symptoms  of  indigestion  and  diarrhea  of  importance. 
This  physician  became  suspicious,  and,  on  having  the  case 
thoroughly  investigated,  was  able  to  inform  the  patient 
that  the  trouble  was  incipient  pellagra. 

The  olfactories  are  not  obtunded  in  this  disease,  but, 
as  in  some  gastric  disorders,  often  seem  to  be  more  acute. 
A  young  woman  at  the  Tabernacle  Infirmary  in  Atlanta 
informed  the  writer  that  she  could  detect  and  differentiate 
odors  since  her  illness  that  would  have  been  beyond  her 
power  during  health.  These  patients,  with  squeamish 
stomachs  at  best,  cannot  eat  or  drink  when  their  olfactories 
are  offended,  and  this  heightened  sense  is  quite  a  problem 
to  manage  at  times.  The  sense  of  smell  is,  in  serious  cases, 
about  the  last  one  to  be  lost. 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA      105 

The  sense  of  taste  must  be  judged  by  different  stand- 
ards. It  is  certain  that  bitter  or  very  sweet  articles  can 
be  distinguished,  but  all  discriminating  taste  is  soon  lost 
in  the  presence  of  the  sore  tongue  and  mouth. 

Another  anomaly  of  sensation,  and  one  of  the  most 
annoying,  is  the  pruritus  in  the  groins,  or  in  the  back  and 
arms.  Sometimes,  in  females,  where  the  vulvovaginal 
margin  is  inflamed,  this  itching  is  so  exasperating  as  to 
almost  drive  them  to  suicide.  In  a  middle-aged  lady, 
seen  in  the  northern  part  of  this  state  some  time  ago,  this 
vulval  and  vaginal  pruritus  caused  her  more  suffering  than 
all  her  other  symptoms. 

The  line  of  demarcation  between  the  nervous  and 
psychic  manifestations  is  dimly  drawn,  and  one  merges 
into  the  other  at  nearly  every  point.  The  psychology  of 
pellagra  has  not  been  studied  long  enough  in  the  United 
States  for  much  authoritative  literature  to  have  been 
accumulated.  We  are,  to  a  large  extent,  dependent  upon 
our  studious  friends  in  Italy  and  France  for  data  in  these 
protean  manifestations  of  pellagra. 

Some  time  ago  the  writer  attempted  to  make  some 
groupings  of  the  psychic  symptoms,  but  with  nearly  every 
new  case  a  new  viewpoint  was  brought  to  view,  leaving 
the  question  more  mixed  and  murky  than  before.  With 
many  misgivings,  therefore,  the  difficult  task  will  be 
undertaken. 

Many  pellagrins  are  quite  sane,  and  always  remain  so, 
but  there  are  few  but  who  will  admit  a  sense  of  mental 
depression,  a  feeling  of  misgiving,  a  vague  unrest,  or  pre- 
monitions of  impending  disaster  at  some  period  of  their 
illness. 


Io6  PELLAGRA 

The  facial  expression  of  pellagra,  after  two  or  three 
recurrences,  is  indicative  of  trouble  and  care.  The  deep- 
ened furrows  attest  the  prolonged  worry,  and  the  oblique 
puckering  of  the  eyebrows  increases  the  grief-worn  ex- 
pression.    The  Jades  in  pellagra  is  worth  attention. 

Insomnia  comes  on  early  and  persists  until  convales- 
cence is  weU  under  way.  Very  few  pellagrins  are  good 
sleepers  while  the  disease  is  making  progress. 

Among  the  first  psychic  symptoms  are  temperamental 
differences,  perhaps  not  realized  by  the  patient.  Unreason- 
ing discontent  at  petty  discomforts  and  unreasoning  anger 
at  slight  annoyances  are  not  uncommon. 

Two  years  ago  a  gentleman  from  a  neighboring  state 
was  under  treatment,  whose  first  symptoms  were  a  dislike 
for  his  two  little  children,  of  whom  he  had  previously  been 
very  fond.  Their  childish  prattle  exasperated  him,  and 
he  admitted  that  he  could  not  understand  why.  These 
peculiar  feelings  of  antipathy  for  his  children  lasted  six  or 
more  months  before  any  other  manifestations  of  a  pella- 
grous nature  became  patent.  He  then  began  to  suffer 
from  indigestion,  loss  of  weight,  and  diarrhea,  and  in  a  short 
while  the  tell-tale  er^^thema  of  the  hands  furnished  the  last 
necessary  link  in  the  diagnosis. 

Next  the  patient  finds  that  thinking  or  calculating  is  an 
effort;  he  becomes  irritable  or  excitable  when  in  the  com- 
pany of  others,  or  morose  and  despondent  when  alone. 

In  the  intermittent  type  there  is  seldom  any  decided 
symptoms  before  the  second  recrudescence,  but  after  that 
a  settled  gloom  begins  to  fall  over  his  spirits.  He  is  sad, 
uninterested  in  what  is  going  on  about  him,  but  conten- 
tious for  his  own  rights.    His  sleeplessness  is  troublesome, 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA     107 

his  surroundings  are  distasteful,  and  he  evinces  a  desire 
to  wander  away.  Sometimes  a  sense  of  having  committed 
a  dreadful  crime  comes  over  the  mentality,  and  fears  of 
detection  and  punishment  are  added  to  the  burden,  heavy 
enough  before.  Obsessions  of  having  injured  loved  ones, 
of  having  been  guilty  of  some  loathsome  transgressions 
against  the  laws  of  God  or  man,  fills  the  sick  soul  with 
grievous  remorse. 

Sometimes,  with  the  burning  and  itching  sensations, 
comes  the  delusions  of  being  burnt.  There  are  also  fre- 
quent delusions  of  persecution.  With  negroes  the  thought 
of  being  bewitched  is  uppermost  in  their  minds,  and  they 
seek  strange  charms  and  curious  objects,  which  they  think 
have  the  power  to  drive  away  the  evil  and  torturing 
spirits.  These  poor  creatures  are  easily  frightened,  easily 
panic-stricken.  They  seek  escape  in  flight,  and  hallucina- 
tions of  poison  often  make  them  refuse  food  and  drink  to 
the  point  of  inanition. 

As  in  some  other  delusional  insanities,  they  are  prone 
to  feel  the  greatest  antipathy  for  and  fear  of  their  dearest 
relatives  and  friends,  attributing  sinister  motives  to  all 
attempted  acts  of  kindness. 

As  the  descent  into  Avernus  is  swift,  so  the  mental  de- 
cline is  rapidly  progressive,  deepening  from  discontent  to 
sadness,  sadness  to  melancholy,  melancholy  to  confirmed 
melancholia,  and  on  down  the  psychic  decline  to  dementia. 
The  writer  is  informed  by  one  alienist  that  about  half  the 
pellagrins  who  applied  to  him  were  already  melancholic, 
though  not  at  the  time  insane. 

Dr.  Holland,  in  describing  these  symptoms,  said,  "  The 
pellagrosi  complain  of  a  sense  of  heat  in  the  head  and 


io8  PELLAGRA 

spinal  cord,  of  tingling  and  darting  pains  in  the  course 
of  the  nervous  system,  of  heat  in  the  limbs,  palms  of  the 
hands,  and  particularly  in  the  soles  of  the  feet;  of  great 
weakness  of  the  limbs,  with  trembling  when  attempting 
to  stand,  and  sometimes  of  contractions  of  the  lower  limbs. 
Their  looks  become  somber  and  melancholy.  Ennui,  de- 
pression of  spirits,  and  mental  imbecihty  increase  with 
the  progress  of  the  malady."  He  also  states  the  pella- 
grosi  afford  a  melancholy  spectacle  of  physical  and  moral 
suffering  at  this  period.  They  seem  imder  the  influence  of 
an  invincible  despondency,  they  seek  to  be  alone,  scarcely 
answering  questions  to  them,  and  often  shed  tears  without 
obvious  cause.  Their  faculties  and  senses  are  impaired, 
and  the  disease,  when  it  does  not  carry  them  off  from  ex- 
haustion of  the  vital  powers,  generally  leaves  them  insen- 
sible idiots,  or  produces  attacks  of  mania,  soon  passing 
into  utter  imbecility  or  idiocy. 

The  following  case,  as  reported  by  Sandwith,  shows 
several  sides  of  pellagra  manifested  in  one  patient,  but  par- 
ticularly the  psychic  aspect,  "  M.  H.,  an  Egyptian  peanut 
woman,  aged  thirty,  was  admitted  to  Kasr  Ainy  on  April 
17,  1897.  She  had  a  well-marked  pellagrous  eruption, 
was  thin  and  weak,  and  abnormally  himgry.  She  passed 
her  excreta  in  bed  or  anywhere  in  the  ward,  and  had  to 
be  prevented  from  eating  dirt.  She  was  melancholic, 
unwilling  to  talk,  and  when  spoken  to  she  repeated  the 
question  and  seemed  unable  to  reply.  At  night  she  would 
get  out  of  her  bed  and  walk  about  the  passages.  She 
had  favus  all  over  her  scalp,  and  ankylostomiasis,  which 
required  four  doses  of  thymol.  We  afterward  found 
from  her  relations  that  one  morning  she  had  gone  down 


Well-marked  manifestations  of  pellagra.     (Courtesy  of  Dr.  Beverly- 
Tucker,  Richmond,  Va.) 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA      109 

to  the  river  to  bathe,  and  had  then  wandered  some  miles 
along  the  river  bank  until  she  reached  Cairo.  On  Oc- 
tober 9th  she  was  discharged  from  the  hospital,  having 
increased  in  weight  thirty- two  pounds;  she  now  smiles, 
talks,  helps  the  other  patients  in  the  ward,  understands  all 
that  is  said  to  her,  and  seems  quite  sensible;  she  has  no 
eruption,  and  her  tongue  is  quite  normal.  Her  knee-jerks 
are  still  too  brisk,  and  she  still  weeps  rather  easily  if  she 
has  any  disagreements  with  the  other  patients." 

The  writer,  not  being  an  expert  alienist,  feels  disposed  to 
defer  to  those  who  have  more  thoroughly  tilled  the  psychic 
field,  and  have  garnered  a  more  seasoned  burden  of  scien- 
tific ideas.  As  such,  Dr.  J.  W.  Babcock  stands  in  the 
-forefront,  and  the  remaining  discussion  concerning  the 
psychology  of  pellagra  is  extracted  from  his  recent  paper, 
"  The  Psychology  of  Pellagra,"  being  made  up  of  his  own 
views  and  the  views  of  others,  as  collated  by  him.  Hack 
Tuke  studied  pellagra  in  Italian  asylums  in  1865.  He 
says,  "  The  patients  were  in  advanced  stages  of  the  disease, 
and  were  all  more  or  less  emaciated,  sallow,  anemic,  and 
presenting  a  miserable  dry,  wrinkled  skin.  They  were 
obtuse  and  inert,  their  mental  state  being  that  of  dementia, 
quiet,  chronic  mania;  or^  in  some  instances,  chronic  melan- 
cholia. None  of  them  was  in  an  acute  maniacal  condi- 
tion." 

The  views  of  Salerio,  director  of  the  asylum  of  San 
Servolo,  Venice,  upon  the  mental  condition  of  his  patients, 
may  thus  be  summarized,  "  They  are  generally  frightened; 
think  they  are  pursued  or  possessed  of  a  devil,  suspicious, 
refuse  food  and  medicine,  and  have  exalted  religious  notions. 
Suicidal    tendencies   may    be   present.     Homesickness   is 


no  PELLAGRA 

common  and  severe.  Finally,  they  are  liable  to  lapse  into 
dementia,  paralysis,  or  tubercular  diseases." 

Bucknill  and  Tuke  quote  also  from  an  early  work  of 
Lombroso,  who  thought  that  one  characteristic  of  pella- 
grins, sane  or  insane,  was  the  greater  moral  impression- 
ability. A  sKght  insult,  the  threatening  of  some  trivial 
danger,  completely  carries  them  away.  If  pellagrous 
insanity  assumes  a  type,  it  approaches  rather  that  of 
chronic  mania  and  dementia  than  that  of  monomania. 
This  Lombroso  ingeniously  terms  "  psychical  catalepsy." 
But,  as  a  rule,  their  sanity  is  of  a  misty,  ill-defined,  con- 
tradictory character,  like  that  produced  by  old  age  or  by 
anemia,  and  differing  on  this  point  from  general  paralysis. 

MorseUi  gives  four  forms  of  pellagrous  insanity,  viz., 
supra-acute  pellagra  (typhoid  pellagra),  pellagrous  melan- 
cholia, pellagrous  dementia,  and  pellagrous  pseudogeneral 
paralysis. 

Babes  and  Sion  say,  in  part,  "  Usually  after  several 
years  of  somatic  pellagra,  psychic  symptoms  come  into 
prominence.  At  first  the  patients  experience  mental 
weakness.  The  peculiar  pellagrous  lunacy  is  preceeded 
by  spasmodic,  then  tonic,  cramps  and  general  bodily  weak- 
ness, and  advanced  to  true  pellagrous  paralysis.  The 
cramps  of  feet,  hands,  and  calf  muscles  are  sometimes 
so  violent  that  they  may  result  in  epilepsy,  contractions, 
and  swooning.  So-called  pellagrous  epilepsy  occurs  as 
the  result  of  spinal  pain,  the  patient  being  drawn  back- 
ward. An  important  condition,  called  pellagrous  tetanus, 
has  been  described  by  Strambio,  opisthotonos  being  a 
common  characteristic  symptom.  Sometimes  the  pa- 
tients are  drawn  forward  and  fall  to  the  groimd.     Chore!- 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA     iii 

form  movements,  especially  of  the  head,  are  observed, 
generally  from  the  incipiency  of  the  disease;  depression 
and  weakness  of  the  memory  are  noted.  Roussel  asserts 
that  in  this  stage  deliria  do  not  appear,  but  that  they  come 
on  in  the  spring  of  the  second  or  third  year.  The  sadness 
may  advance  to  mutism  and  refusal  of  food;  these  condi- 
tions often  being  interrupted  by  lachrymose  or  maniacal 
or  suicidal  episodes.  An  acute  attack  leaves  the  patient 
exhausted,  depressed,  and  hypochondriac.  Such  attacks 
recur  annually  at  about  the  same  time,  the  intellect 
weakens,  and  gradually  dementia  develops. 

"Pellagrous  melancholia  shows  various  stages:  at  first, 
there  are  psychic  impediments,  followed  by  apathy  or 
stupor.  Delusions  of  sin,  of  persecution,  etc.,  appear. 
Mania  is  rare,  but  catalepsy  sometimes  occurs. 

"  When  paralysis  supervenes,  euphoria  appears,  pre- 
senting a  disease-complex  like  general  paralysis,  but  even 
in  advanced  stages  of  the  disease  remissions  may  occur." 

G.  Antonini  writes,  "  Already,  in  the  first  stages  of 
pellagra,  there  appears  a  decided  modification  in  the 
mental  faculties;  there  is  a  great  impressionability,  a 
greater  psychic  excitability;  a  slight  disappointment 
depresses  greatly  the  tone  of  feelings  or  produces  ex- 
cessive reactions  (from  the  want  of  initial  inhibitory 
powers).  In  the  progress  of  the  disease  we  can  have  true 
amentia,  states  of  mental  confusion  common  to  all  psy- 
choses arising  from  exhaustion.  This  state  can  show  sud- 
denly an  aggravation  of  symptoms  and  lead  to  death  with 
a  syndrome  of  acute  delirium  (typhoid  pellagra),  and  yet 
it  can  also  present  in  certain  cases  a  true  progressive 
paralysis  of  pellagra. 


112  PELLAGRA 

"  But  a  frequent  s^Tnptom  is  the  obstinate  refusal  to 
take  food,  such  as  aggravates  painfully  the  already  sad 
picture  of  the  pellagrin." 

Griesinger  notes  that  pellagrous  insanity,  according  to 
Clerici  (^1855),  consists  chiefly  in  a  vague,  incoherent 
dehrium,  accompanied  by  stupor,  loss  of  memory,  and 
by  loquacity  without  special  disorder  of  intelligence  or 
violent  excitement;  the  melanchoHc  state,  which  pre- 
dominates for  a  long  time,  always  passes  gradually  into  a 
state  of  torpor  of  all  the  mental  powers,  with  muscular 
weakness,  which  greatly  resembles  general  paralysis. 

Mongeri  concludes  that  the  pellagrous  psychoses  begin, 
ordinarily,  with  a  period  of  mental  depression  accom- 
panied by  hypochondriac  ideas.  Following  great  mental 
prostration  the  ideas  become  confused.  Later  melan- 
cholia appears,  accompanied  by  hallucinations  of  hearing, 
with  illusions  of  general  sensibility.  Following  this  con- 
dition are  delusions  of  persecution  with  a  tendency  to 
drowning  (the  hydromania  of  Strambio).  Again,  develop- 
ing persecutory  paranoia,  pellagrins  commit  crimes  of  every 
sort  (homicide,  infanticide,  incendiarism,  etc.).  Dementia 
is  the  common  termination. 

According  to  Bianchi,  one  of  the  leading  modem  Italian 
writers,  "  The  nervous  phenomena  dominate  the  scene  in 
pellagra.  We  may  classify  the  different  varieties  in  two 
groups,  the  chronic  and  the  acute.  The  first  is  charac- 
terized by  general  depression,  melanchoha,  confusion, 
slow  dementia,  paresthesias,  and  ataxic  gait.  Contrac- 
tures and  subsulti  are  absent,  although  in  most  instances 
the  reflexes  are  exaggerated.  In  the  acute  form  we  have 
elevation  of  temperature  (39^  to  41°   C),  intense  neuro- 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA     113 

muscular  excitement,  subsulti,  contractures,  muscular 
rigidity,  exaggerated  reflexes,  and  confusion  with  phases 
of  exaltation.  There  are  numerous  intermediate  forms  in 
which  we  observe  a  great  variety  of  psychic  phenomena, 
and  also  alternation  of  excitement  and  depression.  Phases 
of  remission  and  of  apparent  recovery  are  observed,  espe- 
cially at  certain  seasons." 

Regis  announces  that,    "  It  is  recognized  that  the  most 
common  form  of  psychosis  in  pellagra  is  mental  confusion, 
with  melancholy  or  dreamy  dehrium.      This  occurs  more 
or  less  marked  in  most  of  the  cases.     It  is  manifested  by 
an  inertia,  a  passivity,  an  indifference,  a  considerable  tor- 
por; by  msomnia,  hallucinations  often  terrifying,  both  of 
sight  and  hearing;  by  delirious  conceptions,   with  fixed 
ideas  of  hopelessness,  of  damnation,  of  fear,  persecution, 
poisoning,  anxiety,  of  possession  of  devils  and  witches,  of 
refusal  of  food,  and  so  marked  a  tendency  to  suicide  and 
to  suicide  by  drowning  that   Strambio  gave  it  the  name 
hydromania.     This    melancholy    depression,    which    can 
reach,  in  certain  cases,  even  to  stupor,  is  always  based 
upon  a  foundation  of  obtusion,  of  intellectual  hebetude, 
and  of  considerable  general  debility,  which  becomes  per-  • 
manent  and  terminates   by  degrees  in  dementia,  in  pro- 
portion as  the  pellagrous  cachexia  makes  new  progress. 
It   is    accompanied    sometimes   by   a   polyneuritis.     The 
mental  confusion  of  pellagrins  can,  in  place  of  changing 
directly  into  dementia,  turn  to  a  chronic  mental  confusion. 
"  One  may  also  observe  in  pellagra,  as  in  every  chronic 
grave   intoxication,    a   morbid    state   resembhng   general 
paralysis  (pellagrous  pseudogeneral  paralysis).      This  oc- 
curs especially  in  the  cases  where,  instead  of  habitual 


114  PELLAGRA 

melancholy  ideas,  the  patients  present  ideas  of  satisfac- 
tion and  of  wealth." 

Procopiu  discusses  the  subject  at  length,  saying  in  part, 
"  We  have  seen  that  the  character  and  intelligence  of  pella- 
grins change.  They  become  sad,  apathetic,  silent;  in  the 
more  advanced  stage  they  are  melancholy,  and  fall  some- 
times into  an  absolute  mutism  or  respond  with  difl&culty, 
and  have  the  air  of  not  imderstanding  what  is  said  to  them. 

"  Sometimes  this  melancholy  is  accompanied  with 
stupor,  and  leads  the  poor  pellagrins  into  dementia. 

"  It  is  not  rare  in  this  condition  that  an  attack  of  acute 
mania  breaks  out.  At  another  time  the  attack  of  mania 
breaks  forth  suddenly  without  apparent  cause,  or  under 
the  influence  of  a  sunstroke,  a  quarrel,  a  disappointment, 
etc. 

"  Sometimes  it  is  in  the  spring  that  the  excitement,  as 
the  other  symptoms  of  pellagra,  makes  its  appearance,  but 
generally  it  is  later  than  the  others,  and  bursts  forth  at 
the  end  of  the  season  or  even  during  the  summer. 

"  Pellagrous  insanity  has  been  divided  into  acute  and 
chronic  forms.  The  acute  form  is  more  frequent  when 
the  pellagra  is  associated  with  alcoholism;  then  this  form 
presents  the  characters  of  delirium  tremens.  The  acute 
form  often  manifests  itself  in  the  course  of  the  chronic  form, 
but  it  can  also  begin  in  the  state  of  apparent  health. 

"  The  acute  insanity,  in  particular,  which  bursts  out 
suddenly  while  the  patient  is  in  a  state  of  mental  health, 
is  easy  enough  to  cure.  But  when  the  disease  is  advanced, 
and  the  lesions  of  the  nerve-centers  are  profoimd,  cure  is 
difficult,  sometimes  impossible,  especially  in  the  case  of 
dementia.     When  even  a  sensible  amelioration  is  obtained, 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA      115 

the  intellectual  condition  of  the  patients  remains  always 
in  a  marked  degree  of  inferiority." 

From  the  more  recent  treatise  of  Tanzi,  we  learn  that 
"  pellagra  is  almost  always  accompanied  by  psychic  dis- 
turbances, which  often  have  the  character  of  true  mental 
diseases. 

"  A  pellagrous  melancholia  and  a  pellagrous  mania  have 
been  described.  The  characteristic  psychosis  of  pellagra 
is,  however,  amentia,  which  manifests  itself  acutely  in  loss 
of  sense  of  place,  loss  of  memory,  confusion,  hallucinations, 
and  paresthesias,  from  which  there  arise  morbid  impulses 
and  delusions.  Pellagrous  amentia  often  assumes  a 
depressive  form  which  simulates  melancholia,  and  in  some 
cases,  either  from  time  to  time  or  throughout  the  whole 
course  of  the  psychosis,  it  is  accompanied  by  exaltation, 
which  gives  it  some  resemblance  to  mania. 

"  The  first  atack  of  amentia  occurs  after  pellagra  has 
existed  for  some  years  and  has  already  given  rise  to  ery- 
thema and  diarrhea,  and  has  remitted  from  time  to  time. 
In  other  words,  the  pellagrous  lunatic  is,  as  a  rule,  a 
chronic  sufferer  from  pellagra.  But  while  the  pellagra, 
although  chronic,  continues  to  run  an  intermittent  course, 
the  mental  disturbances  associated  with  it  have  the  char- 
acteristics of  an  acute  insanity,  which  corresponds  exactly 
to  amentia,  i.  e.,  to  the  most  typic  of  the  acute  insanities, 
both  as  regards  the  symptoms  and  course. 

**  The  insanity  of  pellagra  is  thus  something  different 
from  common  melancholia  or  from  ordinary  mania.  It  is 
also  something  more  than  simple  amentia.  We  may  re- 
gard it  as  the  combination  of  two  distinct  clinical  pictures; 
namely,  that  of  amentia  in  the  first  attacks,  and  that  of 


Ii6  PELLAGRA 

dementia  in  the  later  and  progressive  phase,  marked  by 
chronic  and  incurable  cachexia.  It  is  an  intermittent 
and  progressive  amentia,  which,  if  not  cured,  or  if  not  early 
fatal,  terminates  in  dementia." 

Babcock  here  inquires  what  is  the  relationship  of  pellagra 
to  progressive  paralysis? 

"  Baillarger  asserts  that  pellagra  may  be  followed  not 
only  by  mania  and  melancholia,  but  also  by  progressive 
paralysis.  Verga  opposes  the  last  opinion,  while  Regis  and 
Piannetta  afi&rm  it." 

Gregor,  in  1907,  recognizing  that  exhaustive  clinical 
observations  on  the  so-called  mental  disturbances  of 
pellagra  were  wanting,  made  careful  analysis  of  the  psychic 
condition  observed  in  72  cases  who  had  been  admitted  to 
the  Bukowina  State  Asylum  from  March,  1904,  to  Sep- 
tember, 1905.  In  1902,  he  says,  Finzi  published  his 
"  Psicose  Pellagrose,"  coming  to  the  conclusion  that  this 
mental  disturbance  is  essentially  an  insanity,  and  that 
the  psychosis  of  pellagra  is  amentia.  This  view,  which 
agrees  with  that  of  Tanzi,  was  combated  by  Vedrani,  who 
maintains  that  the  psychosis  of  pellagra  takes  usually  its 
course  without  serious  disturbances  of  orientation  and 
reason.  On  the  other  hand,  Wamock  claims  that  symp- 
toms of  melancholia  are  the  usual  accompaniments  of  the 
mental  disturbances  in  pellagra,  and  thus  approaches  the 
views  of  the  older  writers,  who  assumed  especially  close 
relations  between  pellagra  and  melacholia.  Thus  Aubert 
tried  to  prove,  in  1858,  that  an  attack  of  pellagra  might 
convert  a  heterogeneous  disease  into  melancholia.  This 
view  was  vigorously  maintained  by  Aubert  against  Bail- 
larger  and  others,  who  held  that  the  psychoses  of  pellagra 


Well-marked  vesication  of  temporal  and  mastoid  regions,  known  as  the 
"  butterfly."     (Case  of  Dr.  G.  A.  Zeller.) 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA      117 

are  polymorphic,  including  meningitis,  mania,  melancholia, 
etc.,  and  even  general  paralysis.  This  view  is  still  main- 
tained, notably  by  Zletarovic,  who  has  observed  the  de- 
velopment on  the  basis  of  nutritive  disturbance  caused  by 
pellagra  of  melancholia  and  mental  weakness  to  complete 
stupor  and  dementia,  but  he  never  observed  mania.  Even 
Lombroso  and  Tuczek,  says  Gregor,  give  only  pictures  of 
psychic  conditions.  Gregor  also  considers  the  studies  of 
pellagrous  insanity  by  Finzi  and  Vedrani  as  inadequate, 
but,  granting  the  absence  of  a  characteristic  symptom- 
complex,  he  says  that  we  must  still  search  for  characteristic 
peculiarities,  since  psychoses,  which  are  in  themselves  not 
specific,  may  assume  certain  symptoms  which  are  to  be 
considered  with  regard  to  their  etiology. 

Gregor  also  included  in  his  study  whether  the  relation- 
ship between  pellagra  and  the  psychoses  was  accidental  or 
casual.  It  will  thus  appear  that  he  attempts  to  reach  a 
much  broader  and  deeper  conception  of  the  neuroses  and 
psychoses  of  pellagra.  He  divided  his  72  cases  into  seven 
groups:  (i)  Neurasthenia,  (2)  acute  stuporous  dementia, 
(3)  amentia  (acute  confusional  insanity),  (4)  delirium 
acutum,  (5)  katatonia,  (6)  anxiety  psychoses,  and  (7) 
maniac-depressive  insanity. 

In  the  following  summary  Dr.  Babcock  gives  Gregor's 
analyses : 

"  Neurasthenia. — The  symptoms  of  Gregor's  first  group 
in  their  details  are  not  specific  of  pellagra,  but  offer  in  their 
totality  a  characteristic  disease-picture. 

"  The  symptoms  are  subjective,  and  include  headache, 
pain  in  the  gastric  region,  vertigo,  paresthesias,  lassitude, 
depression,  a  sense  of  unrest  and  anxiety,  which  may  be 


Ii8  PELLAGRA 

raised  to  a  phobia,  as  well  as  ill-defined  apprehensions. 
There  is  also  a  sense  of  bodily  and  mental  incapacity  and  of 
illness.  Their  conduct  is  normal,  and  the  intellect  may  be 
unimpaired,  but  they  are  incapable  of  mental  and  physical 
exertion.  The  process  of  association  is  distinctly  dis- 
turbed, the  simplest  question  often  being  answered  only 
after  prolonged  hesitation.  With  depression  of  spirits, 
hypochondriac  notions  may  develop  from  a  consciousness 
of  being  pellagrous,  or  experience  in  former  illnesses. 
In  some  cases  there  is  a  sUght  motor  imrest  and  a  desire 
to  move  about,  but,  as  a  rule,  patients  of  this  group  labor 
under  motor  impediment,  and  sink  finally  into  a  condition 
of  apathy  and  resigned  inactivity.  Gregor  admits  that 
these  S}Tnptoms  are  not  specific  of  pellagra,  but  he  sug- 
gests that,  if  these  s}TQptoms  have  lasted  for  several  years, 
the  suspicion  of  pellagra  as  a  causative  factor  should  be 
aroused  in  the  physician's  mind,  even  without  the  presence 
of  the  somatic  stigmata  of  the  disease.  He  also  observed 
that  the  first  attack  of  pellagra  is  more  likely  to  be  accom- 
panied by  neurasthenia,  and  that  this  condition  commonly 
preceded  the  development  of  the  pellagrous  psychoses. 

"  Acute  {Stuporous)  Dementia. — The  milder  cases  of 
this  group  differ  from  the  preceding  group  only  in  degree. 
The  symptoms,  merely  suggested  in  the  former  group, 
exist  here  in  full  force.  The  cases  of  this  group  are  char- 
acterized by  a  distinctly  marked  stupor,  tending  to  remis- 
sions, by  deep  mental  depression,  a  \'i\dd  sense  of  insuffi- 
ciency, and  peculiar  subjective  troubles.  The  dependence 
upon  pellagra  intoxication  can  be  established  by  the 
close  connection  of  the  psychic  disease-picture  w4th  the 
somatic   symptoms   of  pellagra.     The  mental   symptoms 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA      119 

improve  with  the  bodily.  The  external  appearances,  the 
depressed  mental  condition,  the  tendency  to  suicide,  etc., 
explain  the  fact  that  such  cases  are  frequently  considered 
melancholia.  Finzi  contradicts  this  view,  and  places 
these  cases  under  amentia.  Some  of  Tanzi's  and  Vedrani's 
cases  come  under  this  group. 

"  The  patients  give  the  impression  of  being  sick,  as  they 
lie  still  and  apathetic  in  bed  for  weeks,  and  answer  repeated 
questions  only  after  a  painful  effort,  or  not  at  all.  Re- 
quests of  the  simplest  nature  are  carried  out  only  with  hesi- 
tation and  effort,  and  often  the  action  once  begun  is  inter- 
rupted in  its  first  phase,  or  the  request  is  forgotten.  Mostly 
we  are  assured  that  the  patients  are  well  oriented,  and 
often  we  see,  after  the  hesitation  ceases,  that  the  psychic 
activity  is  revived  for  a  short  while,  but,  sometimes  in 
the  height  of  the  disease  orientation  may  be  disturbed. 
Illusions  appear,  the  patients  show  a  sense  of  insufficiency, 
and  sometimes  also  a  hypochondriac  sense  of  sickness  and 
a  consciousness  of  their  psychic  impediments. 

"  In  many  cases,  in  which  the  stupor  developed  gradu- 
ally, a  disturbance  of  psychomotor  activity  was  observed 
without  vivid  mental  disturbances.  On  the  other  hand, 
some  cases,  recognizing  their  incapacity  for  practical  life, 
voluntarily  committed  themselves  to  the  asylum.  Most 
cases  showed  a  gradual  development  of  an  affectless  stupor, 
with  a  final  return  to  their  former  mental  condition. 
Rarely,  psychic  impediments  develop  in  a  relatively  short 
time.  The  sense  of  insufficiency  may  assume  a  distinctly 
melancholy  coloring,  with  suicidal  tendencies.  Again, 
severe  cases  may  assume  temporarily  katatonic  syinptoms 
of  posture  and  motion  sterotypies. 


I20  PELLAGRA 

"  With  this  group  memory  disturbances  were  especially 
well  marked,  as  Tanzi  has  emphasized,  but  weakness  of 
memory  is  not  a  characteristic  of  acute  pellagrous  demen- 
tia. Upon  convalescence  memory  returns  easily,  so  that 
the  apparent  memory  disturbance  is  due  rather  to  the 
general  difficulty  of  performing  psychic  processes  than  a 
weakness. 

"  With  the  rehef  of  the  somatic  symptoms  of  acute 
pellagra  the  mental  symptoms  also  improve.  Besides,  the 
connections  between  pellagra  and  nervous  disturbances  is 
evident,  and  different  mental  symptoms  may  complicate 
the  picture.  It  would  appear  that  melancholia  is  the 
typic  mental  disturbance  of  pellagra.  Tanzi  believes  that 
we  should  call  such  cases  amentia,  and  consider  them  light 
forms  of  this  psychosis.  It  is  in  this  group  that  Tanzi 
would  place  the  typic  cases  of  pellagrous  insanity.  Stupor 
seems  to  promise  a  long  duration  and  an  unfavorable  prog- 
nosis.    Favorable  cases  lasted  from  one  to  six  months. 

"  Amentia  {Acute  Confusional  Insanity). — These  cases 
were  long  continued,  with  a  tendency  to  remissions  and 
intermissions.  After  a  prolonged  period,  which  shows  es- 
sentially the  symptoms  of  the  first  group,  appear  usually 
terrifying  hallucinations,  accompanied  by  violent  motor 
excitement.  The  delirium  was  frequently  followed  by 
stupor  or  existing  stupor  was  interrupted  by  deUrium. 
The  patients  see  the  house  or  village  burning,  enemies 
coming,  wild  animals  attacking  them,  the  de\dl  appears, 
or  machines  cut  off  their  heads.  More  rarely,  they  have 
quite  dreamy  states,  the  heavens  open  and  the  Lord  ap- 
pears, bishops,  priests,  figures  pass  by.  In  imagination, 
they  return  to  the  scenes  of  their  daily  life.    Again,  they 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA      121 

run  away  to  escape  the  flames  or  to  defend  themselves 
against  persecution.  Here  we  have  phenomena  of  motion 
in  connection  with  hallucinations.  If  secluded,  they 
move  about,  are  noisy,  and  knock  upon  the  door.  The 
duration  of  this  excitement  varies  from  a  few  hours  to 
several  days.  These  episodes  are  followed  more  or  less 
by  long  intervals,  in  which  the  patients  are  quiet  in  mind 
and  body.  They  may  be  stuporous,  but  usually  show  only 
slight  disturbance  of  orientation.  Later,  they  pass  into 
a  delirium  like  that  of  meningitis  or  typhoid.  If  diarrhea 
be  present,  the  complex  of  typhoid  pellagra  is  recognized. 
This  may  develop  in  a  chronic  case  or  be  an  acute  process, 
while  in  rare  cases  the  bodily  and  mental  symptoms  may 
improve.  Death  usually  follows  this  typhoid  condition. 
Hallucinations  seem  to  offer  for  the  first  attack  a  de- 
cidedly favorable  prognosis. 

"  Dementia  does  not  always  ensue  upon  a  severe  initial 
attack,  but  develops  in  chronic  cases  of  either  bodily  or 
psychic  pellagra.  The  development  of  katatonic  symp- 
toms, which  may  appear  especially  in  youthful  cases, 
renders  the  diagnosis  difficult. 

"  Acute  Delirium. — The  cases  of  this  group  are  dis- 
tinguished from  those  of  the  third  group  by  the  intensity 
of  the  disease  S3anptoms,  hallucinations,  motor  excitation, 
and  shorter  courses  in  death.  For  this  reason  the  con- 
ception as  acute  delirium  seems  justified. 

"  The  symptoms  of  this  condition  may  occur  without 
the  bodily  signs  of  pellagra,  but  they  usually  occur  syn- 
chronously. Absence  of  a  rise  of  temperature  has  been 
noted  by  both  Italian  and  German  observers. 

"  Groups  2,  3,  and  4  show  a  great  similarity  with  the 


122  PELLAGRA 

mental  symptoms  of  acute  infectious  diseases.  They  might 
therefore,  be  classified  under  the  infective  exhaustive  psy- 
choses. 

"  Katato7tia. — The  katatonic  condition  occurs  with  the 
acute  somatic  pellagra.  Here,  considering  the  concurrence 
of  acute  somatic  and  psychic  pellagra,  we  must  assume  a 
pellagrous  intoxication  as  to  the  causative  factor,  as  in 
pellagrous  neurasthenia.  Many  patients  show  conscious- 
ness of  their  disease.  Hallucinations  may  precede  this 
condition.  Excitement,  stereot}^y,  wild  jactitation,  and 
verbigeration  are  common.  The  katatonic  cases  pass  rap- 
idly into  dementia. 

"  Of  the  cases  of  the  fifth  group,  the  majority  belong  to 
the  katatonia  subdivision  from  the  sjmiptoms,  courses,  and 
termination.  In  three  cases  (females)  excitation  occurred, 
ending  with  stereotypy,  jactitation,  and  verbigeration. 
The  patients  did  not  show  marked  affects.  In  one  case 
hallucinations  preceded  the  condition.  In  all  three  cases 
the  transition  into  dementia  was  rapid,  in  which  posture 
and  motion  stereotypies,  impulsive  actions,  and  talkative- 
ness were  observed.  In  one  case  these  symptoms  were 
followed  by  a  permanent  negative  phase.  In  another 
case,  besides  many  posture  and  motion  stereotypies,  inter- 
change of  negati\dsm  was  observ^ed.  In  one  case  the  kata- 
tonic symptoms  were  marked  from  the  beginning.  A 
male  case  showed,  on  admission  to  the  hospital,  katatonic 
excitations,  and  after  a  few  days  a  remission  followed  by 
another  katatonic  phase.  Six  of  these  cases  ended  in 
dementia  more  or  less  rapidly,  although  remissions  oc- 
curred. 

^^  Anxiety  Psychoses. — The  violent,  fluctuating  anxiety 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA      123 

effect,  the  motor  unrest,  the  anxiety  ideas,  and  the  '  pho- 
nemes '  completing  them,  determines  from  the  first  the 
diagnosis  of  an  anxiety  psychosis.  It  is  true,  this  disease- 
picture  is  compHcated  by  extraneous  features.  The 
patients  show  a  marked  sense  of  insuflSciency,  appear 
slightly  stuporous  in  the  intervals  between  the  attacks, 
and  resemble  cases  of  groups  2  and  3.  Later  the 
anxiety  attacks  have  disappeared,  the  mental  weakness 
increases;  the  second  phase  gradually  lessens  as  it  does 
in  patients  of  the  mentioned  group.  In  the  second  case 
the  psychomotor  weakness  changed  by  turns,  with  violent 
anxiety  effects  and  vivid  motor  unrest.  Temporary  ideas 
of  persecution  and  of  sin,  and,  later,  of  stupor  were  also 
observed.  The  third  case  was  typic  depressive  melan- 
cholia. 

"Maniac-depressive  Insanity. — Of  the  two  cases,  one 
showed  the  condition  of  mania  arising  from  subjective 
pellagrous  troubles.  In  the  other,  mania  was  followed  by 
distinct  stupor." 

The  dementia  following  pellagra  shows  different  forms. 
One  form  develops  an  almost  complete  disappearance  of 
mental  activity,  which  justifies  the  name  "  paralytic." 
But  a  milder  degree  of  dementia  characterizes  the  larger 
number  of  cases.  They  are  oriented,  usually  well  behaved, 
but  dull,  and  showed  a  lack  of  self-restraint,  with  a  tendency 
to  break  out  into  violent  passions  and  impulsive  actions. 

A  simultaneously  existing  alcoholism  has  a  modifying 
influence  upon  the  disease-picture.  Furthermore,  in  many 
individuals,  the  pellagrous  mental  disturbance  does  not 
appear  until  old  age,  and  it  brings  about  a  precocious  senile 
dementia. 


124  PELLAGRA 

There  is  a  distinct  pellagrous  dementia,  like  paresis, 
marked  with  somatic  changes.  An  affirmative  answer  is 
given  to  the  question,  Are  there  disease-pictures  of  demen- 
tia whose  anatomic  basis  is  an  injury  to  the  brain  by  the 
toxins  of  pellagra? 

As  to  the  broad  classifications  of  the  different  psychoses 
of  pellagra,  probably  our  most  practicable  one  has  been 
given  us  by  Dr.  J.  W.  Mobley,  of  the  Georgia  State  Sanita- 
rium. He  says  that  his  cases  fall  principally  under  the 
intoxication  or  infective-exhaustive  group,  and  he  has 
subdivided  them  under  four  headings: 

(i)  Acute  intoxication  psychosis,  with  psychomotor 
suspension. 

(2)  Infective-exhaustive  psychosis,  with  psychomotor 
retardation  or  excitation. 

(3)  SjTnptomatic  melancholia,  with  psychomotor  retar- 
dation. 

(4)  Maniac-depressive,  with  psychomotor  retardation 
or  excitation. 

That  the  various  psychoses  are  of  the  most  complex 
nature  can  be  inferred  from  the  learned  opinions  so  well 
brought  to  our  notice  by  Dr.  Babcock.  That  the  mani- 
festations of  the  subtle  poison  on  the  psychic  centers  may 
be  influenced  largely  by  temperament,  environment, 
previous  health  or  habits,  or  individual  idiosjoicrasies  is 
admitted.  Finally,  when  we  thoroughly  understand  what 
the  toxin  of  pellagra  really  is,  then  may  we  better  read  these 
many  shades  of  disturbed  mentality,  ephermeral  or  lasting 
as  they  may  appear,  and  with  that  knowledge  better  be 
able  to  minister  successfully  to  these  sick  souls. 

So  much  for  the  psychology  of  pellagra. 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA      125 

Ocular  Symptoms. — While  the  ocular  symptoms  in 
pellagra  are  not  distinctive,  there  are  some  abnormalities 
that  are  of  interest  to  consider. 

Dr.  E.  M.  Whaley,  of  Columbia,  studied  this  aspect, 
and  has  drawn  some  interesting  conclusions. 

He  found  that  pellagrins  did  not  carry  their  upper  lids 
as  high  as  they  should,  giving  them  the  appearance  of 
lassitude.  This  has  often  been  noted  by  the  writer,  and 
mentioned  some  months  ago.  Dilated  pupils  are  not  the 
rule,  though  hypersensitiveness  to  light  with  contracted 
pupils  was  frequently  noticed.  Shallow  anterior  chambers 
were  found  by  Dr.  Whaley  in  one-third  of  the  cases. 

A  peculiar  lack-luster  expression  of  the  eyes  has  been  ob- 
served in  a  majority  of  the  cases,  and,  in  the  negroes  the 
brownish  pigmentation  is  deepened  until  it  presents  almost 
a  jaundiced  look.  Pupillary  inequahty  is  not  uncommon. 
It  may  be  said,  however,  that  eye  symptoms  with  pellagra 
do  not  seem  to  be  as  frequent  in  pellagrins  in  the  United 
States  as  in  Europe,  according  to  the  reports  in  hand. 

The  thermal  phenomena  in  pellagra  have  been  the 
subject  of  much  study.  That  the  conclusions  reached  by 
observers  of  cases  in  private  practice  and  physicians  in 
hospitals  or  asylums  should  show  a  variance  is  not  surpris- 
ing. One  writer,  in  reporting  on  100  pellagrins  whose 
temperature  had  been  recorded  for  a  month,  found  more 
or  less  fever  in  80  per  cent.  This  occurred  in  an  asylum, 
and  it  is  reasonable  to  suppose  that  both  degenerative  and 
inflammatory  changes  would  be  found  in  greater  proportion 
than  in  a  given  number  outside  of  such  an  institution. 

It  has  been  the  experience  of  the  writer  in  a  large 
number  of  pellagrins  that,  in  uncomphcated,  ambulatory 


126  PELLAGRA 

cases,  the  temperature  was  practically  always  normal  or 
subnormal — often  the  latter.  Many  of  these  pellagrins 
easily  "caught  cold,"  which  would  give  rise  to  a  temporary 
rise  of  temperature,  but,  apart  from  the  typhoid  condition 
of  pellagra,  which  will  be  considered  later,  the  pellagrous 
process  is  essentially  afebrile. 

Should  this  disease  progress  to  the  "  third  stage,"  as 
some  classify  it,  where  there  is  more  or  less  autotoxemia 
exerting  its  irritating  effect  on  nearly  every  organ  in  the 
body,  there  is,  of  course,  a  natural  ^tendency  to  febrile  ex- 
acerbations, along  with  the  other  abnormal  manifestations 
of  the  diseased  body. 

There  are  occasional  fulminant  cases,  where  a  high  tem- 
perature prevails  from  the  onset  of  the  malady,  and  where 
a  beginning  improvement,  if  the  patient  is  so  fortunate  as 
to  experience  it,  is  ushered  in  by  a  decline  in  the  febrile 
symptoms. 

Many  of  the  ambulatory  cases  habitually  run  a  sub- 
normal temperature  in  the  forenoon,  barely  getting  to 
normal  later  in  the  day. 

The  writer  has  records  of  over  25  of  such  cases,  where 
they  were  regularly  observed  in  the  forenoons,  and  in  but 
few   instances   was    the   temperature   ever   found   above 

97-3°  F. 

Sandwith  positively  and  laconically  sums  up  this  ques- 
tion by  saying,  "  The  temperature  of  an  uncompHcated 
case  of  pellagra  is  always  normal  or  subnormal." 

The  last  phase  of  the  different  clinical  forms  in  which 
this  protean  disease  is  manifested,  and  the  consideration 
of  which  will  close  this  chapter,  is  aptly  termed  typhoid 
pellagra. 


SYMPTOMATOLOGY  AND   COURSE  OF  PELLAGRA      127 

The  fact  that  pellagrins  may  and  do  have  typhoid  fever 
should  be  remembered.  Watson  mentions  seeing  two  cases 
of  typhoid  in  pellagrins  in  19 10,  and  the  writer  saw  one 
typic  case  in  which  not  a  single  classic  symptom  of 
typhoid  fever  was  lacking. 

According  to  Scheube,  typhoid  pellagra  (typhus  pella- 
grosus)  consists  of  an  aggravation  of  all  the  S3anptoms, 
especially  the  mental.  His  description  is  as  follows, 
"  The  whole  muscular  system  is  in  a  condition  either  of 
rigidity  or  intense  tonic  contraction.  The  head  is  buried 
in  the  pillows  and  at  times  convulsively  moved.  On  spon- 
taneous movement  of  the  limbs  a  perceptible  trembling 
and  indications  of  inco-ordination  are  made  manifest,  and 
tremors  and  fibrillary  contractions  are  seen  in  the  face  from 
time  to  time.  The  speech  is  drawling,  tremulous,  and  often 
exhibits  a  nasal  twang.  Frequently  there  are  hyperes- 
thesiae  and  heightened  reflex  excitability,  the  tendon 
reflexes  in  particular  being  always  increased." 

As  to  the  increased  tendon  reflexes,  this  has  not  been 
observed  by  the  writer,  but  rather  the  reverse. 

The  temperature  is  generally  high,  and  may  run  rather 
a  symmetric  course,  not  unhke  true  enteric  fever,  but  this 
typhoidal  condition  may  supervene,  progressing  to  a  fatal 
issue  without  any  rise  of  temperature. 

Procopiu  thinks  this  condition  due  to  the  Eberth  bacillus 
in  the  intestines,  in  which  event  we  have  both  pellagra  and 
typhoid  fever.  His  views  are  not  accepted  by  many  ob- 
servers. 

The  typhoid  condition  of  pellagra  generally  ushers  in  the 
terminal  stage,  and  occurs  after  the  patient  has  suffered 
perhaps   several   recurrences.     There   is   noticed    a   more 


128  PELLAGRA 

rapid  failure  of  strength,  a  more  noticeable  decline  in  the 
mental  powers,  and  an  increase  of  all  the  gastro-intestinal 
symptoms.  The  abdomen  becomes  distended,  the  diar- 
rhea becomes  more  intractable,  and  the  stools  are  often 
involmitary  and  passed  without  the  knowledge  of  the 
patient.  The  stools  also  take  on  that  dreadfully  foul 
odor  of  which  mention  has  been  made.  The  watery  feces 
are  acrid  and  irritating,  and  the  mucocutaneous  areas  in 
and  around  the  anus  or  vulva  become  raw,  perhaps  bleed- 
ing, when  cleansed. 

The  heart,  kidneys,  and  lungs  may  become  involved  as  in 
any  other  acute  exhaustive  condition,  and  a  low  delirium, 
with  subsultus,  opisthotonos,  muscular  rigidity,  convul- 
sions, and  all  that  melancholy  picture  of  a  system  suc- 
cumbing to  a  long-continued  toxemia. 

This  tj^hoid  condition,  which  in  itself  has  no  relation  to 
typhoid  fever  proper,  is  nearly  always  fatal,  seldom  last- 
ing over  two  weeks. 

COMPLICATIONS 

In  the  clinical  course  of  pellagra  there  are  a  number  of 
complications  liable  to  occur. 

The  mental  compHcations  have  been  sufficiently  covered. 

In  Egypt  Dr.  Sandwith  considers  ankylostomiasis  an 
almost  invariable  accompaniment,  often  joined  with  bil- 
harziasis.  The  ankylostomiasis  anemia  predisposes  to 
other  complications,  as  wrist-drop,  paraplegia,  general 
tumors,  epileptic  seizures,  all  following  degeneration  of  the 
spinal  cord;  also  retention  of  the  urine;  herpes  zoster  and 
bronchitis  are  often  noticed.  Malaria,  too,  is  a  frequent 
compHcation. 


SYMPTOMATOLOGY  AND  COURSE  OF  PELLAGRA     129 

In  the  United  States,  especially,  both  the  Uncinaria 
americana  and  the  Amoeba  coli  are  frequently  found  in 
pellagra.  Among  some  investigators  the  ameba  has  so 
often  been  found  in  the  stools  of  pellagrins  that  a  common 
causative  factor  has  been  surmised.  Pyorrhea  alveolaris, 
with  accompanying  ameba  in  the  pus-pockets  about  the 
teeth,  is  not  uncommon.  Occasionally  a  supposedly  pel- 
lagrous sore  mouth  with  free  diarrhea  will  quickly  disap- 
pear under  appropriate  amebacide  treatment. 

One  of  the  most  fatal  complications  is  acute  alcoholism. 
The  pellagrous  condition  seems  to  be  affected  in  a  specially 
malign  manner  by  alcohol,  especially  in  the  form  of  whisky, 
and  it  has  been  frequently  noted  that  hard  drinkers  al- 
most invariably  rim  a  speedy  and  fatal  course. 

About  a  year  ago  the  writer  treated  an  acute  case  of 
pellagra  in  the  Tabernacle  Infirmary  in  a  robust  man 
of  forty-five.  All  the  symptoms  of  a  typic  case  were 
present — the  sore  mouth  and  tongue,  the  erythema  on 
arms,  feet,  and  face,  the  diarrhea,  and  the  mental  depres- 
sion— not  a  symptom  lacking.  Under  the  influence  of 
treatment  he  improved  rapidly,  seeming  convalescent  in 
about  four  weeks.  He  was  known  to  be  addicted  to  whisky, 
occasionally  getting  under  its  influence,  and  he  was  par- 
ticularly cautioned  as  to  the  danger  of  indulging  in  this 
stimulant.  In  spite  of  his  promises,  however,  soon  after 
his  return  home  he  fell  into  an  alcoholic  debauch,  in  which 
he  exposed  himself  to  the  rain  and  cold,  and  otherwise  mis- 
treated his  body.  The  pellagrous  symptoms  immediately 
returned  with  increased  virulence,  terminating  his  life  in 
less  than  two  weeks. 


I30  PELLAGRA 

Syphilis  is  an  occasional  complication,  but,  apart  from 
its  added  burden,  has  no  special  bearing  on  pellagra. 

In  Lombardy,  where  there  is  much  goiter  and  cretinism, 
we  are  informed  that  the  physicians  there  regard  one  dis- 
ease as  the  cause  of  the  other.  In  the  United  States  thyroid 
disease  has  been  noted  in  connection  with  pellagra  to  some 
extent.  Dr.  D.  P.  Curry,  Sanitary  Inspector  of  the  State 
Board  of  Health  of  Kentucky,  has  noted  goiter  in  quite  a 
large  proportion  of  pellagrins  coming  under  his  care. 

Dr.  E.  G.  Jones,  of  Atlanta,  who  has  perhaps  observed 
more  cases  of  goiter  than  any  one  in  the  South,  gives  as  his 
opinion  that  concomitant  pellagra  and  goiter  are  not  more 
frequent  than  concomitant  nephritis  and  goiter,  syphiHs 
and  goiter,  or  tuberculosis  and  goiter.  He  beHeves,  how- 
ever, that  pellagra  may  exert  an  influence  in  "lighting  up" 
a  latent  goiter,  or  that  hyperthyroidism  may,  in  the  same 
manner,  bring  out  a  latent  pellagra. 

One  of  the  most  difficult  complications  to  manage  is  the 
condition  of  marasmus  or  wasting  away,  into  which  the 
pellagrin  sometimes  lapses.  A  liberal  diet  seems  to  aid  not 
at  all,  and  emaciation  rapidly  supervenes,  bringing  mth  it 
apathy,  mutism,  lessened  tendon  reflexes,  and  muscular 
rigidity. 

The  writer  has  at  present  under  observation  a  case  of 
this  sort,  and,  while  the  patient  is  eating  fairly  well  and 
being  given  the  most  nourishing  food,  the  emaciation  is 
progressing,  and  the  prognosis  is  extremely  doubtful. 

Pregnant  pellagrins  seldom  go  to  full  term,  generally 
aborting  before  the  sixth  month. 

Among  the  gynecologic  complications  are  amenorrhea  in 
the  nulliparas  and  menorrhagia  in  the  multiparas.   Among 


Pellagra  in  the  negro.      (Case  from  State  Hospital  for  Insane,  Colum- 
bia, S.  C.) 


SYMPTOMATOLOGY  AND   COURSE  OF   PELLAGRA      131 

other  ills  in  this  category  are  vulvitis,  vulvovaginitis, 
cervical  erosions,  endocervicitis,  endometritis,  and  leukor- 
rhea.  Ovarian  neuralgia,  along  with  the  other  nerve 
pains,  is  present  in  nearly  every  female  pellagrin.  Where 
there  have  been  previous  gynecologic  troubles,  which  have 
been  seemingly  allayed,  an  onset  of  pellagra  sets  up  a 
renewal  in  many  instances. 

Appendicitis  in  the  course  of  pellagra  has  occurred  once 
in  the  service  of  the  writer  at  the  Tabernacle  Infirmary 
Annex  (for  Pellagra).  The  patient,  a  young  unmarried 
woman  of  twenty-five,  while  apparently  progressing  favor- 
ably with  her  pellagrous  infection,  was  suddenly  attacked 
with  acute  appendicitis.  Palliative  measures  having  failed 
to  give  relief,  she  was  operated  on  by  Dr.  J.  L.  Campbell. 
The  appendix,  which  was  removed,  was  hard,  indurated, 
and  dry.  After  the  operation  the  recovery  was  uneventful, 
the  wound  healing  by  primary  adhesion.  The  operation 
did  not  seem  to  unfavorably  affect  the  pellagrous  process, 
while  the  removal  of  the  diseased  appendix  exerted  a  de- 
cidedly beneficial  effect  on  the  gastro-intestinal  symptoms. 
At  present  this  patient  seems  to  be  quite  well. 

This  practically  covers  the  more  frequent  complications, 
though  in  the  presence  of  pellagra,  as  in  any  other  disease  of 
an  exhausting  character,  intercurrent  affections  are  liable 
to  crop  out  at  any  time.  Therefore,  while  watching  for 
the  direct  and  indirect  manifestations  of  pellagra  proper, 
it  is  well  to  be  on  the  qui  vive  at  all  times,  lest  some  unex- 
pected complication,  in  the  already  strenuous  battle,  di- 
minish the  outlook  for  recovery. 


CHAPTER  V 

CLINICAL  REPORTS  AND  DESCRIPTIONS  OF  CASES 
OF  PELLAGRA  FROM  DIFFERENT  SOURCES 

The  previous  chapter  has  purported  to  cover  the  S3rmp- 
tomatology  and  chnical  history  of  this  disease  as  it  has  ap- 
peared to  various  observers  in  different  parts  of  the  globe. 
In  a  malady  of  such  varying  shades  it  is  but  natural  that 
it  should  leave  different  impressions  upon  the  medical 
attendants  in  closest  contact  with  the  sufferers. 

It  is  thought  wise,  therefore,  to  incorporate  in  this 
chapter  a  number  of  clinical  histories  from  widely  scattered 
locaUties,  in  the  hope  that  the  reader  may  obtain  a  broader 
conception  of  this  disease  entity,  whose  presence  has  be- 
come a  problem  to  both  the  student  of  medicine  and  the 
pubUcist. 

The  first  report  is  the  graphic  description  of  a  case  in 
Virginia,  as  reported  by  Dr.  J.  H.  Hewett,  of  Lynnhaven: 

Patient. — H.  A.  S.,  London  Bridge,  Va.,  aged  fifty-six, 
white,  widower,  occupation  milling  and  farming,  was  born 
in  Charlotte  County,  Va.,  reared  in  Pennsylvania  County, 
and  remained  there  the  greater  part  of  the  time  tiU  Feb- 
ruary, 1909,  when  he  moved  to  Princess  Anne  County,  Va. 
He  had  spent  a  year  each  in  Roanoke  and  Lynchburg,  Va., 
where  financial  reverses  made  him  poor.  He  also  spent 
three  years  in  Nebraska,  and  then  returned  to  Virginia. 

132 


PELLAGRA  FROM  DIFFERENT  SOURCES  133 

Family  History. — The  patient's  father  was  killed  in  an 
accident  at  the  age  of  forty-eight;  his  mother  died  of  old 
age  at  eighty-four.  Two  brothers  are  living  and  well. 
Two  brothers  are  dead — one  of  "  B right's  disease,"  the 
other  of  "  brain  fever."  Five  sisters  are  living  and  well. 
There  is  no  history  of  cancer,  tuberculosis,  rheumatism,  or 
insanity  in  any  member  of  the  family.  The  patient's 
father  and  two  of  his  brothers  always  suffered  from  diar- 
rhea whenever  they  ate  bread  from  corn-meal. 

Personal  History. — During  childhood  the  patient  had 
diphtheria,  measles,  mumps,  and  pertussis.  He  had  ty- 
phoid at  eighteen,  malaria  and  gonorrhea  at  twenty-six, 
grip  at  thirty-five.  Since  thirty-five  he  has  always  been 
well  till  the  present  illness.  He  has  noticed  that  bread 
made  from  corn-meal  always  disagreed  with  him,  even  in 
childhood,  producing  diarrhea  and  intense  intestinal  pain. 
His  father  and  two  of  his  brothers,  as  above  stated,  were 
also  similarly  affected  by  corn-meal  bread,  but  he  has  no 
knowledge  that  any  of  them  ever  suffered  with  roughness 
and  desquamating  of  the  skin  at  any  time.  His  average 
weight  is  145  pounds.  He  uses  tobacco  and  alcohol  moder- 
ately. He  is  the  father  of  seven  children,  all  of  whom  are 
dead.  The  second  child  died  at  the  age  of  thirteen.  His 
wife  died  sixteen  years  ago.  They  lived  together  eighteen 
years.     He  denies  lues. 

Present  Illness. — ^The  patient  is  now  a  very  poor  man, 
and  for  the  last  three  years  has  been  living  in  cheap  board- 
ing-houses or  keeping  bachelor's  quarters,  in  which  he  did 
his  own  cooking.  During  the  latter  part  of  last  fall,  owing 
to  the  scarcity  of  work  and  the  high  price  of  flour,  he  was 
compelled  to  eat  more  and  more  corn-meal.     About  the 


134  PELLAGRA 

middle  of  last  December  his  present  diarrhea  began,  very 
mild  at  first,  but  slowly  and  steadily  increasing  in  intensity 
until  about  six  weeks  ago,  when  he  had  from  ten  to  twelve 
movements  per  day,  with  agonizing  tenesmus  and  distress- 
ful abdominal  pains  and  nausea.  For  the  last  month  he 
has  ceased  to  use  corn-meal  in  any  form,  and  the  diarrhea 
has  considerably  abated.  Since  December  he  has  lost 
about  35  pounds  in  weight,  and  has  been  reduced  from  a 
robust,  virile  workingman  to  a  puny,  weak,  sickly  individ- 
ual, to  whom  life  itseK  is  almost  a  burden.  About  ten 
weeks  ago,  while  picking  strawberries,  the  back  of  his 
neck  became  red  and  burned  as  if  sunburnt.  At  the  same 
time  he  suffered  with  intense  headache,  which  was  con- 
fined to  the  region  "  behind  his  ears  and  extended  across 
from  ear  to  ear."  This  continued  for  about  ten  days. 
During  this  period  the  skin  on  the  back  of  neck  began  to 
peel  off.  About  the  same  time  the  skin  over  the  bridge 
of  his  nose  and  the  side  of  his  face,  after  ha\'ing  been  red 
and  painful,  likewise  began  to  desquamate  in  small  and 
large  dry  scales  and  bran-like  particles.  About  six  weeks 
ago  the  skin  on  the  back  of  his  hands  began  to  look  as  if 
it  was  blistered,  being  swollen,  red,  and  painful,  and 
scattered  vesicles  filled  with  serous  exudates  were  formed. 
The  surface  then  became  quite  dry  and  hardened,  cracking 
at  all  joints  and  between  the  fingers.  Both  hands  were 
similarly  affected,  and  about  the  same  extent  of  surface  on 
each  involved.  In  about  a  week  the  skin  on  the  back  of 
the  hands,  fingers,  and  lower  third  of  his  forearms  began 
to  desquamate  in  the  same  manner  as  that  on  his  neck 
and  nose.  About  the  same  time  all  the  toes  of  both  feet 
became  swollen  and  red.     They  burned  slightly  and  itched 


PELLAGRA  FROM  DIFFERENT  SOURCES  135 

in  a  most  intense  manner.  This,  however,  appeared  within 
a  week  and  there  was  never  any  induration  or  desquama- 
tion of  any  portion  of  the  skin.  The  gums  of  his  upper 
jaw  became  swollen  and  red.  There  was  slight  salivation 
for  a  few  days,  but  this  soon  disappeared  and  has  not  since 
recurred.  Since  December  he  has  vomited  only  once, 
that  he  remembers,  but  has  repeated  attacks  of  nausea 
every  day.  During  the  last  ten  weeks  he  has  had  repeated 
attacks  of  vertigo,  often  becoming  dizzy  on  rising  from 
a  sitting  to  a  standing  position,  or  on  rising  from  a  recum- 
bent position,  and  everything  becomes  black  before  his 
eyes. 

General  Examination. — The  patient  is  a  moderately 
emaciated  white  man,  well  advanced  in  years,  with  a  very 
apathetic,  listless  appearance.  He  answers  questions  in  a 
slow,  whining  monotone.  He  is  sitting  up,  and  is  able  to 
walk  around  to  a  limited  extent;  however,  his  gait  is  slow 
and  he  is  evidently  very  weak.  He  gives  a  sUght  groan 
with  each  expiration,  and  appears  to  be  in  great  distress. 
His  hair  is  lusterless,  dry,  and  straight.  The  eyes  react 
sluggishly  to  light  and  accommodation.  All  of  the  upper 
teeth  have  been  removed.  The  lower  ones  all  show  more  or 
less  marked  decay.  Pyorrhea  alveolaris  is  quite  extensive. 
Respiration  is  slightly  labored.  The  skin  everywhere  has 
a  muddy  pallor.  The  heart,  lungs,  and  thorax  show  noth- 
ing abnormal.  The  abdomen  is  scaphoid  in  shape.  The 
liver,  spleen,  and  kidneys  are  not  palpable.  The  deep 
reflexes  of  the  upper  and  lower  extremities  are  increased. 
Plantar  stimulation  gives  a  slight  dorsal  flexion  of  the  great 
toe.  No  patellar  nor  ankle  clonus  can  be  obtained.  There 
is  no  Rhomberg's  sign,  but  slight  tremor  on  protruding  the 


136  PELLAGRA 

tongue.  The  patient  gives  no  history  of  urinary  trouble 
at  any  period  of  his  Hfe,  though  for  the  past  four  months 
he  has  had  to  get  up  once  or  twice  every  night  to  mic- 
turate; otherwise,  negative.  Freshly  voided  urine  shows 
a  specific  gravity  of  1032;  deep  amber  color;  sugar  and 
albumin,  negative. 

Skin. — Over  the  back  of  the  neck,  extending  upward  to 
the  hair-line  and  downward  to  level  of  upper  border  of  the 
soft  shirt  collar,  the  skin  is  of  a  dirty  rose-pink  color,  and 
everywhere  covered  with  small  and  medium-sized  patches 
of  dry  exfohating  epidermis.  This  superficial  epidermis 
may  be  easily  removed  and  no  bleeding  points  remain. 
The  same  appearance  in  condition  may  be  noted  on  each 
side  of  the  neck,  extending  as  far  forward  as  the  anterior 
border  of  the  sternocleidomastoid  muscle.  Similar  areas 
over  the  cheeks,  sides  and  bridge  of  the  nose,  and  the 
lateral  aspect  of  the  forehead  fuse  and  become  continuous 
with  these  areas  on  the  neck.  The  symmetric  situation 
of  these  lesions  on  each  side  of  the  head  is  marked.  Over 
each  side  of  nose,  especially  marked  in  the  region  of  the 
alae  nasi,  there  appears  a  h3^ersecretion  of  the  sebaceous 
glands.  The  orifices  of  each  gland,  filled  with  grayish-white 
sebaceous  material,  gives  the  skin  a  white,  stippled  appear- 
ance. The  surface  of  the  skin  over  these  areas  is  quite  dry 
and  rough  to  the  touch.  In  certain  places  there  is  a  small 
amount  of  sebaceous  exudate  attached  to  the  plaques  of 
dead  epidermis,  giving  them  the  character  of  thin  crusts. 
Along  the  lower  areas  on  the  neck  and  upper  margin  of  the 
areas  on  the  forehead  there  is  a  line  of  intensified  brownish 
pigmentation.  The  margins  of  these  roughened  areas  is 
everywhere  sharp  and  well  defined.     Symmetrically  situ- 


Case  of  pellagra,  showing  erratic  course  of  the  disease.     Patient  did  not 
complain  of  feeling  ill.     (Courtesy  of  Dr.  J.  W.  Babcock.) 


PELLAGRA  FROM  DIFFERENT  SOURCES  137 

ated  on  each  side  of  the  neck,  just  below  the  lower  margin 
of  the  roughened  area,  is  a  lenticular-shaped  area  of  deeply 
reddened  skin  over  which  the  superficial  skin  appears 
shriveled.  These  areas,  the  patient  tells  me,  have  ap- 
peared in  the  last  few  days,  and  have  the  same  appearance 
as  the  large  areas  when  they  were  first  noticed.  The 
mucous  membranes  of  the  lips  and  conjunctivas  are  pale 
but  moist.  Skin  over  the  chin  and  the  anterior  portion 
of  the  neck  appears  pale  and  slightly  taimed,  but  otherwise 
normal.  Over  the  sternum,  on  the  right  side,  there  is  a 
lozenge-shaped  area,  measuring  about  5  by  2  cm. ;  beginning 
above  at  the  sternoclavicular  articulation,  extending  down- 
ward and  inward  to  the  level  of  the  upper  border  of  the 
third  rib,  there  is  a  brownish  pigmented  area  of  desquamat- 
ing epidermis.  On  the  left  there  is  a  similar  area,  but 
smaller.  Symmetrically  situated  on  each  shoulder,  over 
the  acromial  process,  the  spine  of  the  scapula,  and  the  in- 
fraspinous  fossa,  the  skin  is  roughened,  harsh,  scaly,  and 
covered  with  numerous  patches  of  brownish,  desquamat- 
ing epidermis.  The  skin  underlying  all  of  these  areas  is 
pale,  slightly  thinned,  and  very  dry  and  rough.  There  are 
also  similar  areas  symmetrically  situated  over  each  deltoid 
and  each  triceps  muscle.  The  skin  over  each  olecranon 
process  shows  the  same  appearance  as  that  noted  above, 
i.  e.,  a  dry,  harsh,  desquamating  superficial  skin,  and  a  dry, 
pale,  slightly  thirmed  underlying  skin;  but  after  exposure 
to  the  sun  for  a  few  minutes,  as  was  done  when  I  attempted 
to  photograph  the  patient's  hands,  the  underlying  skin 
assumed  a  rose-pink  color,  similar  to  that  to  be  described 
over  the  hands  and  arms.  The  whole  surface  of  both 
hands,   especially   the   backs   of   the  fingers   and  hands, 


138  PELLAGRA 

and  the  lower  third  of  both  arms,  are  everywhere  quite 
rough  and  scaly.  The  skin  of  the  dorsum  of  the  hands, 
wrists,  and  lower  portions  of  the  forearms  is  of  a  diffuse 
erythematous  rose-pink  color.  Scattered  over  these  areas 
are  innumerable  small  and  large  patches  and  plaques  of 
dried  and  desquamating  epidermis.  Along  all  the  natural 
furrows  of  the  hands  and  wrists,  at  the  interphalangeal 
joints,  and  in  between  the  fingers,  there  are  deep  cracks. 
These  cracks,  the  patient  tells  me,  were  much  deeper  a  few 
weeks  ago.  They  were  also  at  that  time  more  painful  and 
tender,  and  would  often  bleed  after  slight  injury.  Only 
a  few  of  them  now  extend  through  the  true  skin,  and  they 
are  all  healing  rapidly.  The  skin  over  the  sides  of  the 
fingers  and  the  backs  of  several  of  the  interphalangeal 
joints  is  markedly  thickened  and  has  the  appearance  of  a 
saw  file.  The  skin  on  the  palms  of  the  hands  is  pale,  but 
the  superficial  layer  is  dry  and  harsh  to  the  touch.  In 
places  it  may  be  peeled  off  in  large  thick  plaques,  leaving 
a  comparatively  normal  subjacent  skin.  The  line  of 
separation  between  the  affected  and  the  non-affected  skin 
is  sharp  and  well  defined. 

Mentality. — The  lady  of  the  house  tells  me  that  the 
patient  often  has  fits  of  extreme  irritabihty,  when  nothing 
can  be  done  to  please  him,  and  he  is  extremely  fault- 
finding and  quarrelsome.  He  shows  complete  orientation, 
and  can  remember  dates  and  events  accurately,  but  he  has 
to  think  over  many  of  them  for  a  considerable  time.  He 
can  perform  simple  problems  in  arithmetic,  but  with  none 
of  the  accuracy  or  rapidity  that  might  be  expected  of  one 
who  had  once  controlled  a  business  house  with  a  capital 
stock  of  five  thousand  dollars,  as  he  once  did,  according 


PELLAGRA  FROM  DIFFERENT  SOURCES  139 

to  his  story.  He  complains  of  difficulty  in  buttoning  his 
shirt  and  coat,  but  this  is  most  probably  due  to  the  anes- 
thesia produced  by  the  drying  and  desquamation  of  the 
superficial  skin  over  the  tips  of  his  fingers. 

This  word-picture,  descriptive  of  pellagra,  as  given  by 
Dr.  Hewett,  is  hardly  lacking  in  any  detail,  showing  a  care- 
ful study  of  the  clinical  manifestations  and  recorded  with  a 
care  for  detail  worthy  of  high  commendation.  The  reader 
will  do  well  to  study  it  closely. 

The  next  case  reported  is  taken  from  the  description  of 
Dr.  Howard  Fox,  of  New  York,  a  patient,  formerly  under 
the  care  of  Dr.  J.  M.  Daves,  of  Blue  Ridge,  Ga.,  and  seen 
by  Dr.  Fox  through  the  influence  of  Dr.  Bernard  Wolff,  of 
Atlanta. 

This  case  was  also  seen  by  Dr.  J.  J.  Watson  and  Dr.  J. 
W.  Babcock,  who  both  pronounced  it  a  typic  case  of  pel- 
lagra of  rather  a  mild  type. 

Dr.  Fox's  well-couched  description  is  as  follows: 

The  patient,  H.  C.  H.,  is  a  farmer,  fifty-one  years  old, 
born  in  Blue  Ridge,  Fannin  County,  Ga.,  where  he  has 
lived  most  of  his  life.  His  father  died  at  fifty  years  of  age 
of  an  unknown  disease.  His  mother  died  at  sixty-three  of 
the  "  grip."  The  patient  is  the  father  of  thirteen  children, 
eight  of  whom  are  living  and  healthy.  Four  died  as  in- 
fants. Two  of  these  were  twins,  two  others  members  of  a 
triple  birth.  One  was  born  dead  at  full  term.  The  pa- 
tient's wife  had  never  had  any  miscarriages,  and  had  al- 
ways enjoyed  good  health.  No  member  of  his  family  had 
ever  suffered  from  a  disease  similar  to  the  present  one. 

The  patient  had  always  been  a  considerable  drinker  of 
whisky.     He  gave  no  history  of  syphilis,   but  admitted 


I40  PELLAGRA 

having  suffered  from  an  obstinate  attack  of  gonorrhea 
when  about  eighteen  years  old.  At  twenty-four  he  suf- 
fered from  an  attack  of  malaria  lasting  six  months.  With 
the  exception  of  these  illnesses  he  had  always  enjoyed  good 
health  till  about  two  years  ago.  Since  then  he  had  gradu- 
ally "  fallen  down  "  in  general  health  and  strength. 

The  first  definite  symptoms  noted  were  gradual  loss  of 
appetite  and  an  occasional  "  roaring  "  in  the  ears.  The 
latter  s}Tnptom  had  been  constant  for  the  last  ten  months. 
Previous  to  this  time  the  tinnitus  had  occurred  in  attacks 
lasting  a  few  days. 

About  the  first  of  April,  1908,  the  patient  noticed  a  red- 
ness and  swelling  of  the  backs  of  the  hands,  which  he  at 
first  ascribed  to  sunburn.  The  redness  was  followed  by 
scaling,  which  lasted  for  two  months.  There  were  a  few 
**  blisters  "  upon  the  hands  at  first,  but,  except  at  the  out- 
set, there  were  no  subjective  symptoms  whatever.  After 
the  disappearance  of  the  eruption  the  hands  looked  en- 
tirely normal.  During  the  following  winter  the  patient's 
general  health  improved. 

About  the  end  of  March,  1908,  an  eruption  similar  to  the 
first  appeared  on  the  backs  of  the  hands.  This  was  also 
followed  by  scaling  several  weeks  later,  leaving  the  hands 
smooth,  though  darker  in  color.  During  the  past  ten  months 
there  had  been  three  or  four  such  attacks  of  redness  and 
scaling  on  the  hands.  At  no  time  had  the  hands  become 
entirely  normal.  The  attacks  had  appeared  in  spite  of 
precautions  taken  by  the  patient  to  protect  his  hands 
from  the  sun  by  wearing  gloves  and  by  using  bland  oint- 
ments. There  had  never  been  any  oozing  from  the  affected 
area  nor  had  there  been  any  subjective  symptoms  except, 


PELLAGRA  FROM  DIFFERENT  SOURCES  141 

as  before  said,  at  the  outset  of  the  attacks.  Six  months 
ago  there  was  an  eruption  of  the  face  and  of  the  dorsal 
surfaces  of  the  feet  somewhat  similar  to  that  of  the  backs 
of  the  hands.  This  has  now  disappeared,  leaving  the  skin 
in  apparently  normal  condition. 

The  patient  stated  that  his  tongue  had  been  red  during 
the  past  summer.  According  to  Dr.  Wolff,  it  presented  a 
fiery-red  appearance  when  seen  two  months  ago.  He  had 
not  suffered  from  severe  diarrhea  except  for  a  short  period 
of  a  few  weeks  recently.  His  bowels  have  been  "  more  or 
less  loose  "  during  the  past  summer. 

The  patient  had  become  more  and  more  depressed  since 
the  beginning  of  his  illness  and  despaired  of  ever  regaining 
his  health.  He  did  not  suffer  from  sudden  fits  of  anger 
nor  excitement.  His  memory,  according  to  his  statement, 
became  very  poor. 

Examination  showed  the  patient  to  be  a  poorly  nourished 
man  of  medium  height.  His  facial  expression  was  very  dull. 
He  was  slow  in  answering  questions,  his  memory  was  evi- 
dently poor,  and  he  was  mentally  depressed.  The  pupils 
were  equal,  moderately  dilated,  and  reacted  normally  to 
light  and  accommodation.  His  tongue  was  slightly  red- 
der than  normal.  The  mucous  membrane  of  the  lips  and 
mouth  were  practically  normal  in  appearance. 

The  backs  of  the  hands  presented  a  symmetric  bluish- 
red  area,  looking  like  a  fading  eczema.  This  area  covered 
the  backs  of  the  wrists,  extending  slightly  around  the 
radial  side  to  the  anterior  surface.  The  distal  border  of 
the  area  did  not  quite  extend  to  the  first  interphalangeal 
joints.  The  skin  was  smooth  and  had  an  atrophied  ap- 
pearance, though  to  the  touch  it  did  not  feel  very  abnormal. 


142  PELLAGRA 

The  heart,  lungs,  and  abdominal  organs  were  apparently 
normal.  The  pulse  was  regular  in  force  and  frequency, 
slow,  full,  and  showed  marked  thickening  of  the  peripheral 
arteries.  There  was  no  tenderness  over  any  portion  of  the 
spine.  The  gait  was  apparently  normal.  There  was  no 
ataxia.  There  was  some  sHght  rigidity  of  the  muscles 
of  the  legs.  The  patellar  reflexes  were  moderately  in- 
creased, especially  on  the  left  side.  There  was  no  ankle- 
clonus,  no  Babinski  reflex.  There  were  no  sensory  changes 
in  the  skin.  The  cutaneous  reflexes  were  normal.  Ex- 
amination of  the  urine  showed  no  abnormal  constituents. 

An  examination  of  the  blood,  made  by  Dr.  Elizabeth 
Finch,  was  as  follows :  Hemoglobin  (Fleischel) ,  66  per  cent. ; 
red  cells,  4,264,000;  white  cells,  9500.  Differential  leuko- 
cyte count  showed  polynuclears,  278,  55.6  per  cent.;  large 
mononuclears  and  large  lymphocytes  (22  transitionals), 
16,  38,  7.6  per  cent.;  small  mononuclears  and  small  lympho- 
cytes, 141,  28.3  per  cent.;  eosinophiles,  37,  7.4  per  cent.; 
mast  cells,  6,  1.2  per  cent.  No  nucleated  red  cells.  Red 
cells  pale,  but  apparently  normal  in  size. 

An  examination  of  the  nose,  throat,  and  ears,  made  by 
Dr.  D.  Bryson  Delavan,  showed  the  following:  "Naso- 
pharynx: Typic  chronic  catarrhal  inflammation  of  the 
upper  nasopharynx  and  Eustachian  tubes,  with  obstruc- 
tion of  the  latter.  Ears:  Condition  appeared  to  be  char- 
acteristic of  the  above.  No  apparent  connection  with  the 
general  disease." 

After  this  lucid  description  by  Dr.  Fox  another  case  will 
be  described,  this  one  by  Dr.  M.  L.  Perry,  of  Parsons, 
Kansas,  and  reprinted  from  the  Proceedings  of  the  Ameri- 
can Medico-Psychological  Association,  held  at  Washing- 


PELLAGRA  FROM  DIFFERENT  SOURCES  143 

ton,  May,  1910.  Few  observers  are  as  able  as  Dr.  Perry 
to  paint  the  shifting  changes  in  the  mentality  of  these 
sufferers.     His  report  follows: 

I.  H.,  white,  female,  aged  thirty-four,  single,  no  occupa- 
tion. Admitted  to  Osawatomie  State  Hospital  1901, 
and  transferred  to  Parsons  State  Hospital  1904.  Family 
history  negative.  Patient  had  first  convulsion  at  age  of 
five  months,  during  an  attack  of  cholera  infantum.  Fol- 
lowing this  acute  illness  convulsions  continued  in  a  light 
form,  gradually  becoming  more  frequent  and  severe  as 
she  grew  older.  The  first  evidence  of  active  mental  dis- 
turbances at  age  of  fourteen.  On  admission  patient  was 
in  vigorous  general  health,  weighing  170  poimds.  Feeble- 
minded, with  marked  facies  epilepticus.  She  had  two 
short  attacks  of  acute  gastritis  in  the  spring  of  1908,  and 
severe  status  in  July  of  same  year,  otherwise,  she  remained 
in  good  general  health  until  the  fall  of  1909.  A  note  in 
the  case  record,  dated  June  19,  1909,  says,  "  A  big,  strong 
woman,  whose  health  is  excellent.  Occasionally  with  a 
severe  seizure  she  has  to  go  to  bed  for  a  day,  complaining  of 
feeling  nervous  and  uncomfortable,  and  does  not  rest  well. 
Usually  is  active  and  a  good  worker  when  not  cross.  Has 
about  fifteen  seizures  per  month.  Rather  loud  and  bois- 
terous, but  most  of  the  time  is  good  natured,  although  rough 
in  her  manner  and  language." 

In  September,  1909,  she  began  to  complain  of  not  feeling 
well,  with  vague  pains  in  abdomen  and  lower  extremities, 
anorexia,  and  some  loss  of  weight.  Developed  delusions 
that  she  had  been  poisoned,  and  became  depressed,  refusing 
to  eat.  Was  nauseated,  and  would  induce  vomiting  at 
times  by  putting  her  finger  in  her  throat.     Bowels  con- 


144  PELLAGRA 

stipated.  Tongue  furred.  Temperature  and  pulse  nor- 
mal. The  sensory  symptoms,  at  first  vague  and  more  or 
less  indefinite,  soon  became  very  pronounced.  Patient 
complained  much  of  severe  pain  in  abdomen,  pelvis,  and 
extremities,  and  soreness  on  pressure,  and  was  put  to  bed. 
A  note  on  case  record,  dated  October  i8,  1909,  says, 
"  Patient  has  complained  recently  of  severe  pain,  both  on 
urination  and  defecation.  Examination  showed  a  very  fine 
thick  h}Tnen,  the  opening  through  which  was  so  small  that 
no  vaginal  examination  was  undertaken.  The  mucous 
surfaces  about  the  external  genitals  were  somewhat  con- 
gested and  sensitive.  Examination  of  the  anus  showed  a 
well-marked  fissure.  \\'ith  slightly  inflamed  mucous  mem- 
brane. The  fissure  was  cauterized  with  nitrate  of  silver." 
Urine  was  negative.  Patellar  reflexes  aboHshed,  and  she 
soon  developed  paresthesias  in  various  parts  of  the  body 
and  a  marked  analgesia  in  both  lower  extremities.  There 
was  sHght  fever  present,  with  pulse  somewhat  weak  and 
accelerated.  She  had  some  difficulty  in  walking,  owing 
to  weakness  and  ataxia  in  lower  limbs.  A  diagnosis  of 
multiple  neuritis  was  made  and  patient  treated  accordingly. 
There  was  some  improvement  observed  during  the  month 
of  November,  but  a  note,  dated  December  i,  1909,  states, 
"  For  several  days  the  patient's  condition  has  been  more 
serious,  pulse  has  been  hard  to  count,  and  general  weak- 
ness is  pronounced.  Has  been  on  strychnin,  xs"  grain 
every  three  hours,  for  two  days.  To-day  was  given  one 
pint  of  water,  by  rectum,  several  times  with  benefit.  She 
has  developed  a  severe  stomatitis,  which  has  caused  much 
annoyance."  Tongue  red  and  fissured,  with  small  blisters 
and  ulcers  aroimd  the  edge.     Mucous  membrane  on  in- 


PELLAGRA  FROM  DIFFERENT  SOURCES  145 

side  of  the  cheeks  also  showed  ulcers.  The  inflammation 
extended  into  the  pharynx,  making  it  difficult  to  swallow 
solid  food.  Patient  at  times  refused  to  eat  on  account  of 
sore  mouth.  Temperature  ranged  from  normal  to  100.5° 
F.  Bowels  still  inclined  to  be  constipated,  although  loose 
occasionally  for  a  day.  She  passed  small  amounts  of  puru- 
lent material.  Condition  of  patient  varied  somewhat 
from  week  to  week,  but  with  no  marked  change  imtil  the 
latter  part  of  January,  1910.  She  was  able  to  be  up  and 
dressed  part  of  the  time.  The  case  record  shows  on  Jan- 
uary 30,  1910,  a  sudden  rise  of  temperature  to  104°  F.,  fol- 
lowing a  few  days  of  more  sensory  complaint  than  usual. 
Fever  reduced  by  sponging.  At  this  time  she  developed 
an  erythema  on  the  dorsum  of  both  hands,  particularly 
marked  over  the  knuckles.  The  hands  in  a  few  days  be- 
came very  rough,  with  fissures  extending  through  the  skin, 
making  open  sores  in  several  places.  No  pain  nor  itching 
of  hands  present,  but  they  were  quite  sore  when  handled. 
The  erythema  did  not  extend  above  the  wrist,  but  there 
were  patches  on  the  elbows.  At  this  time  a  tentative  diag- 
nosis of  pellagra  was  made.  Some  improvement  was  ob- 
served during  the  next  week,  but  a  note  on  February  9th 
says,  "  During  the  last  few  days  patient  has  been  very 
sick,  temperature  course  irregular,  much  of  the  time 
being  high,  reaching  105°  F.  on  one  occasion.  She  has 
suffered  much  from  severe  vomiting.  Treatment  symp- 
tomatic, cold  sponging,  strychnin,  and  nourishment  as 
freely  as  possible."  During  these  febrile  attacks  there 
appeared  a  pronounced  erythema  over  nose  and  cheeks, 
bat-shaped  in  outline.      Later  on  the  skin  on  both  hands 

and  face  became  scaly,  and  on  the  hands  much  thinned  and 
10 


146  PELLAGRA 

roughened.  There  was  considerable  pigmentation,  with  a 
quite  well-defined  line  of  demarcation  at  the  wrists.  Ex- 
amination of  blood-smears  showed  a  reduced  number  of 
leukocytes  and  considerable  evidence  of  anemia. 

The  mental  condition  of  the  patient  underwent  a  very 
decided  change  during  her  last  illness.  Her  emotional 
state,  which  had  previously  been  rather  exalted,  became 
much  depressed,  with  occasional  outbursts  of  pronounced 
excitement,  the  patient  being  at  times  kept  in  bed  with 
extreme  difficulty.  There  was  a  partial  return  of  the  con- 
vulsions toward  the  end  of  her  illness,  and  a  slight  tendency 
to  spasticity,  but  no  contractures.  Sensory  symptoms 
continued  to  the  end.     Died  April  16,  1910. 

A  marked  pecuHarity  of  this  case  is  the  decided  fever  at 
times,  so  different  from  the  usual  afebrile  condition  of 
pellagra. 

The  next  report  is  of  an  Egyptian  pellagrin,  under  the 
care  of  Dr.  Wamock,  and  reported  by  Dr.  Sandwith: 

An  Egyptian  woman,  aged  twenty-one,  was  admitted 
to  the  asylum  on  May  15,  1904,  with  a  history  of  pellagra 
for  the  last  six  months.  She  was  married  seven  months 
before  admission,  but  her  husband  had  divorced  her  be- 
cause she  wandered  about  for  no  reason,  was  sleepless, 
performed  the  rehgious  "  zikr,"  talked  to  herself,  and 
used  to  fall  down  when  she  tried  to  walk.  On  admission, 
she  was  sleepless,  pulse  feeble,  tongue  could  not  be  seen; 
she  had  pellagrous  rash  on  her  elbows,  legs,  and  tro- 
chanters, and  her  knee-jerks  were  greatly  exaggerated. 
Her  expression  was  very  dull,  she  complained  of  being 
ill  in  her  body,  and  stated  that  she  was  possessed  by  a 
devil.      On   the   same  day  she  had  a  sort  of  fit,  during 


/fLi.AaacL.KASElc 


Egyptian  case  of  pellagra.     Markedly  indurated  skin  on  back  of  hands. 
(Service  of  Dr.  Warnock.) 


PELLAGRA  FROM  DIFFERENT  SOURCES  147 

which  the  attendant  stated  that  she  had  contraction  of 
the  limbs  and  head  for  a  short  time,  but  no  loss  of  con- 
sciousness. She  could  walk,  but  refused  to  stand  up  when 
asked  to  do  so,  and  was  quite  demented,  forgetful,  and 
unable  to  converse  rationally.  She  was  excited  at  times, 
incoherent  and  noisy,  but  was  able  to  support  herself  if 
she  grasped  something  to  pull  herself  up  by.  A  month 
later  she  was  still  restless,  always  talking,  dirty  in  her 
habits,  but  had  no  definite  delusions.  In  July  she  still 
had  staggering  gait,  was  subject  to  falls,  and  her  muscles 
were  contracted,  apparently  involuntarily.  Her  brother, 
who  visited  her,  said  that  she  had  had  a  black  rash  on  her 
face  and  hands  that  "  would  not  wash  off."  Her  brother 
denied  any  syphilis  in  the  family,  but  had  evidently  him- 
self suffered  from  pellagra.  In  August  she  was  still  child- 
ish and  dirty  in  her  habits,  still  obliged  to  catch  hold  of 
something  to  support  her  when  standing  up,  and  her 
speech  was  still  defective,  especially  the  labial  sounds,  but 
she  was  more  cheerful  and  beginning  to  put  on  weight. 
In  November  she  was  fatter,  quiet,  but  still  childish,  and 
her  speech  still  defective.  She  was  able  to  walk  and  in- 
clined at  this  time  to  do  some  work.  She  laughed  inanely, 
and  volunteered  that  she  had  been  under  sorcery,  induced 
by  a  man  in  her  village,  but  the  effects  had  now  passed  off. 
In  December  it  was  noted,  "  does  some  work  and  has  some 
sense,  but  is  shy  and  imbecile  in  demeanor."  In  January, 
eight  months  after  admission,  she  had  improved  so  much 
that  she  was  able  to  be  discharged,  quite  strong  physically 
and  able  to  work,  but  mentally  still  somewhat  childish, 
thinking  she  had  been  under  sorcery. 
The  following  case,  which  came  under  the  care  of  the 


148  PELLAGRA 

writer,  vnll  illustrate  the  progress  of  a  seemingly  rather 
mild  case  of  pellagra  in  an  aged  woman,  but  which,  on 
account  of  non-resistance,  soon  resulted  fatally: 

Mrs.  W.  P.,  aged  seventy-one,  was  seen  October  i,  1910, 
and  found  to  be  a  slender  and  fragile  woman,  looking 
fully  her  age.  She  was  referred  by  another  physician,  who 
had  noted  a  rough,  scaly  appearance  of  both  hands,  ex- 
tending up  both  forearms  like  a  gauntlet. 

Her  past  histor\'  was  not  productive  of  interest,  except 
that  she  reported  a  "  spring  feeling,"  as  she  termed  it,  for 
the  past  three  years,  during  which  time,  for  about  two 
months  in  the  early  summer,  she  suffered  from  lassitude 
and  slight  diarrhea.  For  this  she  had  gone  to  the  moun- 
tains, each  time  seeming  to  obtain  reHef  and  strength. 
Being  in  comfortable  financial  circumstances,  she  had  been 
able  to  take  ever}-  care  of  herself,  and  attributed  the  diar- 
rhea to  dietetic  indiscretions;  the  slight  erythema  she 
thought  was  caused  by  exposure  to  sim  and  wind  during 
her  tramps  in  the  mountains. 

Upon  physical  examination,  her  heart  was  found  to  be 
normal,  though  the  second  sound  was  not  very  sharp;  her 
limgs  were  normal;  her  arteries  were  somewhat  sclerosed, 
but  her  blood-pressure  was  not  high.  The  arcus  senilis 
was  most  distinct  in  her  eyes.  Her  stomach  was  normal  in 
size,  but  ptosed  about  two  inches.  Her  abdominal  walls 
were  extremely  thin,  permitting  the  peristalsis  of  the  in- 
testines to  be  plainly  seen.  Her  muscular  system  was 
flabby,  her  limbs  were  wobbly,  and  her  hands  tremulous. 
Her  voice  was  quavering  and  uncertain.  There  were  no 
dermal  lesions  except  on  her  hands  and  forearms,  these 
showing  a  rather  faded  erythema.     Her  tongue  showed 


PELLAGRA  FROM  DIFFERENT  SOURCES  149 

a  surface  denuded  of  epithelium  around  the  edges,  and  was 
pale  and  tremulous.  She  did  not  complain  of  her  tongue 
being  sore,  but  said  her  taste  was  not  discriminating  as  it 
had  formerly  been.  At  present  everything  tasted  the  same 
to  her. 

Her  appetite  was  poor,  her  food  seemed  to  "  lie  heavily  " 
in  her  stomach  for  several  hours  after  eating,  and  articles 
that  formerly  agreed  with  her  seemed  to  nauseate  and  dis- 
tress her.  Her  bowels  were  loose,  moving  four  or  five 
times  daily,  preceded  by  colicky  pains,  the  movements 
frothy  and  foul  smelling.  She  also  noted  a  great  difficulty 
in  controlling  her  anal  sphincters,  on  several  occasions 
having  soiled  her  linen  before  she  could  get  to  the  toilet. 
She  admitted  being  more  forgetful  than  usual,  but  her 
husband  remarked  on  her  seeming  decline  in  mentality, 
for  she  had  been  a  woman  of  fine  force  of  character. 

Treatment  seemed  at  first  to  aid  her,  but  not  for  long. 
Her  hands  began  to  desquamate,  appearing  for  a  time  as  if 
they  were  improving,  but  it  was  soon  noted  that  the  skin 
under  the  desquamated  epidermis  seemed  to  desiccate  and 
become  rough  as  soon  as  it  was  exposed.  Her  general  com- 
plexion, too,  became  ashy,  her  skin  taking  on  a  harsh  and 
wrinkled  appearance.  Her  diarrhea  remained  about  the 
same,  though  by  October  20th  at  least  half  of  her  move- 
ments were  involuntary.  Her  appetite  diminished  from 
day  to  day,  so  that  it  was  with  the  utmost  difficulty  that 
she  could  be  induced  to  partake  of  any  food  at  all.  This 
disinclination  to  eat  arose  both  from  anorexia  and  a  sito- 
phobia,  for  she  feared  the  distress  that  followed  each  meal. 
Her  mouth  began  to  be  somewhat  sore,  and  the  mucous 
membranes  of  her  lips,  before  pale,  now  became  a  cherry 


ISO  PELLAGRA 

red.  With  failing  bodily  strength  came  weakened  men- 
tality, and  in  a  dreamy,  aimless  way  she  would  answer  ques- 
tions or  make  requests  pertaining  to  her  comfort.  During 
her  illness  the  temperature  was  never  over  98°  F.,  and 
generally  about  97°  F. 

With  a  steady  downward  course  she  declined,  complain- 
ing but  little,  and  scarcely  seeming  to  realize  that  she  was 
ill.  During  the  last  five  days  of  her  life,  she  was  semi- 
comatose, her  bowels  moved  involuntarily,  her  reflexes 
were  aboUshed,  dysphagia  was  marked,  her  pulse  was  slow 
and  feeble,  and  she  succumbed  with  hardly  a  struggle  on 
November  12th. 

Had  this  patient  been  young  and  resistant,  the  disease 
would  have  probably  assumed  an  entirely  different  as- 
pect. 

To  show  how  widely  variant  pellagra  may  appear,  one 
more  case,  this,  too,  under  the  observation  of  the  writer, 
will  be  cited.  As  in  the  first,  the  whole  picture  was  one  of 
weakness  and  non-resistance,  the  second  will  show  a 
sthenic  form  of  pellagra,  in  which  a  vigorous  vitality  seems 
to  have  conquered. 

The  patient.  Miss  A.,  twenty-four  years  old,  previous 
health  good,  was  seen  in  July,  191 1,  in  an  apparently 
precarious  condition  with  pellagra.  She  had  lost  a  younger 
sister  two  months  previously  with  this  disease,  the  fatal 
result  having  occurred  in  the  second  recurrence.  The 
rest  of  the  family  were  well,  and  both  parents  seemed  free 
from  any  pellagrous  taint. 

She  had  always  been  a  healthy,  though  rather  nervous, 
girl,  and  in  the  spring  of  19 10  she  suffered  from  "  diarrhea 
with  sunburned  hands."     The  diarrhea,  as  has  so  often 


Author's  case  of  pellagra.     Patient  seems  to  have  recovered. 


PELLAGRA  FROM  DIFFERENT  SOURCES  151 

been  the  case,  was  ascribed  to  errors  in  diet,  and  the  sunburn 
to  exposure.  This  seemingly  slight  indisposition  disap- 
peared during  the  summer,  and  throughout  the  fall  and 
winter  she  enjoyed  her  usual  health. 

In  March,  191 1,  the  diarrhea  and  erythema  reappeared, 
and  with  the  added  impression  of  her  sister's  illness,  being 
much  like  hers,  she  began  to  grow  melancholy  and  appre- 
hensive of  dire  results.  She  continued  to  grow  worse,  both 
as  to  the  gastro-intestinal  symptoms  and  the  erythema,  the 
latter  showing  in  symmetric  patches  on  Her  face,  neck, 
breast,  and  lower  limbs.  During  this  time  also  her  parents 
were^much  troubled  by  her  frequent  emotional  outbursts, 
and,  when  the  other  sister  unexpectedly  died,  they  and  she 
woke  up  to  the  gravity  of  the  situation. 

She  was  sent  to  several  resorts  in  the  hope  of  restoration 
to  health,  but  she  steadily  declined  until  she  was  brought 
to  Atlanta  for  treatment. 

When  seen  by  the  writer  she  presented  a  melancholy 
picture.  The  erythema  was  quite  extensive  in  some  places, 
mostly  on  the  nose,  forehead,  and  neck,  having  assumed  a 
dingy  hue,  while  the  palmar  and  plantar  surfaces  had 
become  a  distinct  black,  showing  an  inclination  to  peel  off 
in  several  places.  In  several  of  the  interphalangeal  spaces 
cracks  had  formed  from  which  exuded  much  serum.  Her 
tongue,  lips,  and  buccal  surfaces  were  absolutely  raw,  also 
the  vulvovaginal  margins  and  the  anal  margins.  A  sero- 
sanguinolent  discharge  from  the  irritated  vagina  and  anus 
kept  the  inner  aspect  of  the  thighs  and  buttocks  almost 
raw,  while  the  relaxed  and  incompetent  anal  sphincters 
permitted  the  watery  feces  to  spurt  out  at  frequent  inter- 
vals. 


152  PELLAGRA 

Mentally  she  was  in  fully  as  pitiable  a  state.  A  dreamy 
delirium,  broken  only  by  horrid  dreams  and  phobias,  was 
present,  out  of  which  she  was  aroused  with  difficulty.  The 
reflexes  were  much  exaggerated.  Occasionally,  when  she 
showed  lucid  inter^^als,  she  complained  of  numbness  and 
formication,  and  was  fearful  that  her  heart  would  suddenly 
stop  beating. 

Her  temperature  for  two  weeks  seldom  ran  under  ioo°  F. 
in  the  mornings,  sometimes  going  up  as  high  as  104°  F.  in 
the  evenings. 

Under  energetic  treatment  she  began,  in  about  two  weeks, 
to  show  signs  of  improvement,  practically  all  of  her  symp- 
toms showing  the  same  uphft.  As  her  bowels  unproved,  so 
did  her  mind  and  her  erythema,  while  her  sore  tongue  and 
mouth  rapidly  lost  their  Jier}'  red  and  raw  appearance.  The 
dry  and  rough  skin  peeled  off  in  great  flakes,  lea\dng  a  pink 
and  exceedingly  tender  surface.  Her  feces  assumed  a 
semisolid  consistency,  though  she  still  had  to  be  quite  care- 
ful to  promptly  evacuate  her  bowels  when  the  desire  mani- 
fested itself,  or  she  would  soil  her  linen. 

Her  mind  also  became  clear,  but  she  was  somewhat 
emotional  and  easily  excited  to  tears. 

This  young  patient  was  in  September  able  to  return  home, 
and  at  present  is  reported  as  apparently  well.  Whether 
this  improvement  will  or  vt-ill  not  be  permanent,  time  alone 
will  tell. 

The  description  of  these  several  cases  in  widely  scat- 
tered localities  covers  pellagra  in  its  major  and  plainer 
forms.  The  many  variations,  the  many  deviations  from 
the  classic  picture,  the  many  at}"pic  or  compHcated  cases, 
will  have  to  be  recognized  and  treated  on  their  merits. 


PELLAGRA  FROM  DIFFERENT  SOURCES  153 

It  behooves  the  thoughtful  reader  to  scan  with  dis- 
criminating care  the  many  shades  of  bodily  and  psychic 
deviations  from  the  normal  as  set  forth  here,  and  the  way 
will  be  paved  for  a  better  understanding  of  the  chapter  on 
Diagnosis  and  Prognosis, 


CHAPTER  VI 

PATHOLOGY   AND   MORBID   ANATOMY   OF 
PELLAGRA 

The  morbid  anatomy  of  pellagra  is  neither  constant  nor 
characteristic.  The  chronicity  of  the  disease,  the  variety 
of  symptoms,  the  many  complications  and  intercurrent 
affections,  preclude  the  naming  of  any  single  definite  set 
of  changes  as  belonging  to  its  pathology. 

Tuczek,  as  quoted  by  Lavinder,  described  as  part  ap- 
pearances of  cachexia  the  following:  Wasting  of  adipose 
and  muscular  tissues,  brittleness  of  the  bones  (fragilitas 
ossium),  atrophy  and  fatty  degenerations  of  the  internal 
organs  (chiefly  those  innervated  by  the  vagus),  heart, 
kidneys,  spleen,  intestines,  liver,  and  lungs. 

He  also  describes  three  further  groups  of  morbid  changes : 
(i)  Intestinal — atrophy  of  muscular  coat,  with  occasional 
hyperemia  and  ulceration  of  the  lower  part  of  the  tract; 
(2)  abnormal  pigmentation  (similar  to  senile  change),  espe- 
cially of  ganglionic  cells,  heart  musculature  (brown  at- 
rophy), hepatic  cells,  and  spleen;  (3)  ulcerations  in  the 
nervous  system.  The  variously  described  conditions  of 
hj^eremia,  anemia,  edema,  and  at  times  inflammatory 
affections  of  the  central  nervous  system  and  its  coverings, 
together  with  the  obliteration  of  the  central  canal  of  the 
cord,  he  regards  as  not  peculiar  to  pellagra,  but  as  ac- 

154 


PATHOLOGY  AND  MORBID  ANATOMY  OF  PELLAGRA    155 

companying  conditions,  present  in  many  chronic  affections 
of  the  central  nervous  system  and  in  senility. 

The  findings  in  the  brain  are  in  most  cases  negative,  ex- 
cept for  occasional  fatty  degeneration  or  calcification  of  the 
intima  of  small  blood-vessels  and  pigmentation  in  the  ad- 
ventitial coats.  In  cases  where  a  long-continued  psychosis 
had  led  to  a  high  degree  of  imbecility,  atrophy  of  the  cere- 
brum may  be  found.  In  the  cord  the  changes  are  fairly 
constant  and  important:  degenerations  in  the  lateral  col- 
umns in  the  dorsal  region,  and  in  the  posterior  columns  in 
the  cervical  and  dorsal  regions;  very  few  changes  are  found 
in  the  lumbar  cord. 

Summarizing  the  data  obtained  from  153  examinations 
of  the  cerebrospinal  fluid  of  106  cases  of  pellagra,  W.  F. 
Lorenz,  Special  Expert,  U.  S.  Public  Health  Service,  reports 
as  follows: 

(i)  A  lymphocytosis  of  the  cerebral  fluid  does  not  occur 
in  uncomplicated  pellagra. 

(2)  Globulin  excess  of  the  spinal  fluid  is  only  occasionally 
observed. 

(3)  Lange's  colloidal  gold  chlorid  test  is  uniformly  nega- 
tive in  pellagra. 

(4)  The  Wassermann  is  negative  with  a  few  exceptions. 
In  this  investigation  the  exceptions  were  moribund  cases 
which  gave  weakly  positive  reactions  with  blood-serum. 

(5)  The  spinal  fluid  findings  would  seem  inconsistent 
with  a  conception  that  pellagra  is  an  infectious  disease  of 
the  central  nervous  system.  (PubHc  Health  Reports. 
Reprint  218.) 

In  autopsies  performed  by  Dr.  Sandwith,  he' noted  great 
emaciation  and  cachexia,  generally  with  marked  anemia. 


156  PELLAGRA 

There  may  be  definite  exfoliating  patches  on  the  parts  of 
the  body  exposed  to  the  sun  during  life,  or  there  may  be 
only  a  little  roughness  of  these  parts,  but  the  skin  there, 
if  carefully  examined,  will  be  foimd  to  be  atrophied, 
and  there  is  a  general  diminution  of  subcutaneous  fat. 
Microscopically,  there  is  sclerosis  of  the  blood-vessels, 
papillae,  and  corium,  as  well  as  atrophy  of  the  homy 
layer. 

The  muscles,  heart,  liver,  kidneys,  and  spleen  share  in  the 
general  atrophy. 

The  lungs  sometimes  show  tubercular  lesions.  The 
stomach  reveals  no  lesion  to  the  eye,  but  the  walls  of  the 
intestines  are  thinner  than  usual,  and  show  a  sUght  shed- 
ding of  the  superficial  layers  of  the  epithehum,  with  atrophy 
of  the  muscular  tissue.  There  is  no  ulceration  of  the  in- 
testines. Many  naked-eye  lesions  have  been  reported  by 
various  observers  as  occurring  in  the  brain,  but  the  only 
constant  one  is  atrophy  of  the  cortex  of  the  convolutions, 
especially  the  frontal. 

Dr.  Sandwith  took  from  Egypt  to  England  two  brains, 
which  Dr.  Mott  examined  for  him,  though  they  did  not 
arrive  in  a  satisfactory  condition.  There  were,  however, 
found  in  them  evidences  of  chronic  sHght  but  diffuse 
meningomyehtis. 

Dr.  Mott  found  no  decided  changes  in  the  spinal  cord 
until  it  was  prepared  and  carefully  examined.  Tuczek, 
though,  in  1893,  found  in  8  autopsies  in  Italy  that  all  of 
them  showed  symmetric  sclerosis  of  the  columns  of  Goll. 
In  6  cases,  also,  there  was  lateral  'sclerosis  in  the  dorsal 
region,  and  in  i  case  he  found  cervical  anterior  sclerosis. 

In  1899  Dr.  E.  F.  Batten  made,  for  Dr.  Sandwith,  many 


PATHOLOGY  AND  MORBID  ANATOMY  OF  PELLAGRA    157 

sections  of  three  pellagrous  cords,  and  furnished  the  follow- 
ing report  on  them: 

Marchi's  Method. — The  paleness  of  the  posterior  columns 
was  very  noticeable,  but  under  the  microscope  no  recently 
degenerate  fibers  could  be  seen.  The  cells  of  the  anterior 
horns  were  pigmented. 

Weigert-Pal  Method.— The  lack  of  fibers  in  the  poste- 
rior columns  was  very  marked,  both  sacral  and  lumbar  re- 
gions being  affected  equally.  In  the  mid-dorsal  region  a 
pair  of  normal  roots  entered  the  cord,  and  wedged  itself  in 
between  the  atrophied  fibers  of  the  median  and  external 
columns;  this  root  could  be  traced  up  to  the  upper  cervical 
region,  where,  again,  the  incoming  roots  contained  more 
normal  fiber.  A  small  wedge-shaped  tract  was  also  visible 
just  outside  the  anterior  horns  of  the  cervical  region. 

Aniline-blue-black  Method. — The  increase  of  the  con- 
nective tissue  in  the  posterior  columns  was  very  marked, 
and  distributed  itself  in  exact  correspondence  with  the  con- 
dition of  the  roots  above  described,  namely,  a  pair  of 
roots,  which  had  undergone  no  degeneration  in  the  dorsal 
region,  showed  no  increase  of  the  connective  tissue  in 
the  area  it  occupied  in  the  cord.  There  was  no  increased 
vascularity  of  the  cord,  the  cells  of  the  anterior  horn  and  the 
nucleus  and  nucleolus  were  distinct,  the  increase  of  the 
connective  tissue  was  limited  to  the  posterior  columns,  ex- 
cept in  the  wedge-shaped  tract  above  described  in  the 
cervical  region,  which  appeared  darker  owing  to  the  small- 
ness  of  the  film  in  this  area. 

Van  Giesen's  Method. — There  was  no  evidence  of  any 
recent  inflammatory  action  in  the  gray  matter.  There  was 
some  thickening  of  the  walls  of  the  smaller  vessels,  espe- 


158  PELLAGRA 

dally  in  the  posterior  columns,  though  it  was  not  limited 
to  this  region. 

The  posterior  roots  of  the  cervical,  dorsal,  and  lumbar 
regions  were  also  examined  in  this  case  by  Marchi,  Weigert- 
Pal,  and  Strobe's  methods.  Marchi's  method  showed  very 
little  recent  degeneration,  though  it  was  obvious,  from  the 
lack  of  staining,  that  a  very  considerable  amount  of  de- 
generation had  taken  place,  and  this  was  made  evident 
by  staining  by  the  Weigert-Pal  method.  The  greatest 
amount  of  destruction  seemed  to  have  taken  place  in  the 
dorsal  and  lumbar  regions,  and  to  a  lesser  extent  in  the 
cervical  region;  the  same  condition  was  also  shown  by 
the  Strobe  stain;  only  a  few  axis-cylinders  could  be  seen 
in  each  root. 

This  patient  died  of  pellagra  and  chronic  kidney  dis- 
ease, but  there  was  no  possibility  of  knowing  how  many 
years  she  had  suffered  from  pellagra. 

According  to  Dr.  Sandwith's  opinion  the  cord  degenera- 
tion would  appear  to  be  of  root  origin,  and  affects  the 
extramedullary  as  well  as  the  intramedullary  portion  of 
the  posterior  roots.  The  degeneration  in  the  cervical  re- 
gion of  this  cord  was  most  marked  in  the  columns  of  Goll, 
the  columns  of  Burdach  being  affected  to  a  lesser  degree. 
Since  then  he  has  had  many  other  sections  cut  and  ex- 
amined by  experts,  but,  unfortunately,  nothing  of  patho- 
logic interest  was  revealed.  The  absence  of  cord  degenera- 
tion in  these  cases  was  due  to  the  fact  that  the  patients  had 
either  had  pellagra  for  too  short  a  time — one  year  or  less — 
or  that,  though  they  had  suffered  from  pellagra  for  three 
years  or  more,  the  clinical  signs  of  the  disease  were  not 
very  far  advanced.     In  other  words,  spinal  cord  degenera- 


PATHOLOGY  AND  MORBID  ANATOMY  OF  PELLAGRA    159 

tion,  as  discovered  by  the  microscope,  is  a  comparatively 
late  lesion  in  the  disease. 

The  following  remarks  from  a  recent  paper  of  Dr.  J.  D. 
Long  show  his  views  as  to  certain  pathologic  lesions  in  pel- 
lagra : 

"  As  to  the  lesions  on  various  parts  of  the  body,  in  every 
case  of  pellagra  in  which  radiographs  were  made  the  plates 
showed  deposits  in  the  spinal  foraminae  which  apparently 
produced  pressure  on  the  nerves.  As  to  the  part  played 
by  toxic  degeneration  of  the  nerves  themselves,  I  can  only 
repeat  what  I  was  told  by  Dr.  Achucaro,  of  the  Govern- 
ment Hospital  for  the  Insane,  Washington,  D.  C,  that 
experiments  show,  when  various  tissues,  such  as  nerves, 
muscle,  and  fat,  are  allowed  to  decompose,  that  the  nerve, 
being  the  most  highly  specialized  of  all  the  tissues,  shows 
evidences  of  degeneration  first. 

"  It  is  possible  that  several  factors  may  be  concerned 
in  the  seasonal  recurrence  of  the  disease:  first,  renewed 
activity  and  renewed  infections  with  amebae  in  the  spring 
of  the  year;  second,  engorgement  of  the  intestines,  due  to 
chilling  of  the  body  surface;  third,  the  growth  of  molds  in 
food  products,  with  resulting  changes  in  these  products, 
which  could  favor  fermentation  in  a  person  already  de- 
bilitated. 

"  As  to  the  degeneration  of  the  posterolateral  columns  of 
the  spinal  cord,  Marie  made  the  observation  that  the  de- 
generation began  in  the  posterior  of  the  spinal  nerves.  The 
radiographs  showed  that  the  pressure  does  come  on  the 
posterior  roots  of  these  nerves  at  about  the  site  of  the 
ganglion.  Further,  at  the  only  autopsy  I  could  obtain,  it 
was  noticed  that  the  foramina  were  so  filled  with  what 


i6o  PELLAGRA 

seemed  to  be  a  firm  cartilage-like  deposit  that  the  nerves 
were  wedged  therein,  and  a  large-sized  sewing-needle  or  a 
Japanese  tooth-pick  could  not  be  pushed  through  the 
foramina.    The  spinal  canal  was  also  partially  filled. 

"  It  may  be  seen  from  the  skeleton  and  the  radiographs 
that  the  foramina  in  the  cervical  region  decrease  in  size 
from  above  downward,  whereas  the  nerves  increase. 
These  facts  would  seem  to  account  for  the  lesions  on  the 
hands  (fifth,  sixth,  seventh,  eighth  cervical,  and  first 
dorsal),  face,  and  neck  (third  and  fourth  cervical). 

"  With  reference  to  the  dorsal  nerves,  Gray  says,  '  The 
roots  of  the  dorsal  nerves  are  of  small  size,  and  vary  but 
slightly  from  the  second  to  the  last.'  Examination  of  the 
skeleton  shows  these  foramina  to  be  larger  than  the  lower 
cervical,  and,  therefore,  there  are  no  lesions  on  the  parts 
innervated  by  the  dorsal  nerves. 

"  The  lesions  on  the  legs  and  feet  are  due  to  pressure 
on  the  first  and  second  sacral  nerves,  of  which  Gray  says, 
'  The  roots  of  the  upper  sacral  nerves  are  the  largest  of  all 
the  spinal  nerves,  while  those  of  the  lowest  sacral  and  coc- 
cygeal nerves  are  the  smallest.'  The  foramina  are  larger 
than  the  other  intervertebral  foramina,  but  are  more 
tortuous,  and,  as  the  spinal  canal  in  the  sacnun  is  incom- 
plete posteriorly  and  flattened,  it  is  possible  that  any  de- 
posit here  will  produce  pressure-symptoms  as  in  the  other 
vertebrae." 

Dr.  J,  C.  Bardin,  pathologist  of  the  Central  State  Hospi- 
tal, Petersburg,  Va,,  has  recently  made  postmortems  on 
5  cases  of  pellagra,  and  has  carefully  investigated  the 
blood  in  14.  He  has  rendered  a  most  interesting  account 
of  his   findings  in    the   October   issue   of   the   American 


PATHOLOGY  AND  MORBID  ANATOMY  OF  PELLAGRA    i6l 

Journal  of  Insanity,  and  the  following  are  abstracts  of  his 
article: 

He  considers  that  pellagrins  are  specially  prone  to  con- 
tract tuberculosis — particularly  intestinal  tuberculosis — 
and  seem  to  be  an  easy  prey  to  intestinal  parasites  at  nearly 
every  stage  of  the  disease.  The  pellagrous  lesions  of  the 
intestines  naturally  render  them  more  vulnerable  to  any 
organism  that  might  happen  to  enter.  Dr.  Bardin  opines 
that  cases  of  intestinal  tuberculosis  occurring  in  patients 
suffering  with  pellagra  cannot  be  detected,  save  in  rare 
instances,  until  postmortem  is  done. 

In  the  American  Journal  of  Insanity,  July,  1913,  Dr. 
Bardin  commented  on  the  marked  eosinophilia  in  pellagrins 
infected  with  intestinal  parasites,  which,  however,  does  not 
affect  the  lymphocyte  counts.  He  further  remarks:  "One 
who  has  not  observed  the  feces  of  negroes  can  have  no  idea 
how  heavily  they  are  sometimes  infected  with  these  organ- 
isms; and  it  is  to  be  wondered  at  that  more  of  our  cases  of 
pellagra  do  not  show  this  condition." 

Were  it  possible  to  give  a  definite  sequence  of  tempera- 
ture to  pellagra,  so  that  it  could  be  differentiated  from 
tuberculosis,  it  would  be  possible,  by  keeping  charts  of  all 
patients  in  the  diarrheal  period,  to  detect  those  com- 
plicated by  tuberculosis  of  the  bowel.  Unfortunately  this 
has  not  been  practicable. 

Three  out  of  the  5  cases  examined  postmortem  showed 

tuberculosis  of  the  bowel,  and  a  fourth  showed  healed  lesions 

of  the  lungs.     Another  case,  that  did  not  die,  was  diagnosed 

tuberculosis  of  the  lungs,  and  was  sent  to  a  tuberculosis 

colony.     While    recovering    from     tuberculosis,    pellagra 

developed.      This  patient  went  through  a  typic  attack  of 
11 


i62  PELLAGRA 

pellagra,  but  both  the  pellagra  and  tuberculosis  improved 
during  the  same  time,  and  the  recovery  from  both  seemed 
complete. 

The  writer  does  not  doubt  that  tuberculosis  compUcates 
many  of  these  pellagrous  cases,  especially  those  with  per- 
sistent diarrhea.  In  analyzing  the  findings  in  14  cases, 
considerable  discrepancy  was  found  to  exist  between  the 
blood  of  those  pellagrins  having  tuberculosis  and  those 
not  having  it.  The  discrepancies  occurred  principally 
in  the  differential  leukocyte  counts. 

The  blood  examinations  were  made  by  Dr.  Bardin,  as 
far  as  possible,  while  the  pellagrous  symptoms  were  at 
their  height — that  is,  when  there  was  marked  diarrhea, 
erythema,  and  stomatitis.  In  making  the  red  and  white 
counts  the  usual  technic  was  employed,  and  at  least  six 
different  fields  were  counted  and  averaged  in  each  ex- 
amination. A  variation  of  six  leukocytes  was  allowed  be- 
tween the  highest  and  lowest  field  counts.  At  least  four 
white  counts  were  made  in  each  case  and  the  results  aver- 
aged. 

The  results  of  the  several  tables  gotten  up  by  Dr.  Bardin 
show  that  there  is  usually  a  well-marked  reduction  in  the 
number  of  red  blood-cells,  a  diminution  in  the  percentage 
of  hemoglobin,  and  but  little  change  in  the  leukocytes  in  aU 
the  cases. 

The  differential  counts  show  a  variable  reduction  in  the 
percentage  of  pol3miorphonuclears;  a  marked  variability 
in  the  percentage  of  small  lymphocytes;  a  fairly  constant, 
but  small  increase  in  large  lymphocytes;  and  a  marked 
diminution  in  eosinophiles. 

Leaving  out  some  interesting  tables  showing  the  blood- 


PATHOLOGY  AND  MORBID   ANATOMY  OF  PELLAGRA    163 

counts  in  cases  complicated  by  tuberculosis,  we  find  that 
Dr.  Bardin  observed  that  in  uncomplicated  pellagra  the 
small  lymphocytes  seem  to  be  increased  in  proportion  to 
the  severity  of  the  skin  lesions,  though  this  does  not  always 
hold  good.  He  has  also  observed  that  the  more  chronic 
the  case,  the  more  small  lymphocytes  there  will  be  rela- 
tively. He  has  been  struck  with  one  or  two  things  in  cases 
of  uncomplicated  pellagra  that  occur  with  too  great  a 
regularity  to  be  accidental.  They  are  an  increase  in  lymph- 
ocytes, with  a  corresponding  reduction  in  polymorpho- 
nuclears and  a  marked  reduction  in  eosinophiles.  These 
variations  from  the  normal  blood-picture  seem  fairly  con- 
stant. Further  than  this  Dr.  Bardin  does  not  commit 
himself. 

The  studies  of  the  cytology  of  the  blood  by  Drs.  O.  S. 
Hillman  and  P.  A.  Schule  have  not  disclosed  any  con- 
stant abnormahty.  A  lymphocytosis  was  observed  in 
approximately  75  per  cent,  of  the  cases  examined  by  them. 

The  writer  is  able  to  obtain  a  personal  report  from  Dr. 
E.  C.  Thrash,  of  Atlanta,  who  has  recently  held  four  post- 
mortems on  pellagrins  whose  illness  has  lasted  a  variable 
length  of  time.  As  a  result  of  these  postmortems  he  has 
formed  certain  conclusions  embodied  herein.  The  result 
of  all  profound  anemias  is  a  cloudy  swelhng  of  the  cell 
structures  of  the  various  organs  of  the  body  with  other 
atrophies.  This  is  so  not  only  of  toxic  conditions  result- 
ing from  poisons  emanating  from  organic  living  matter, 
but  also  from  chemical  poisons.  There  is  no  exception  to 
this  rule  in  pellagra. 

In  the  more  acute  cases  there  is  hyperemia  and  cell 
migration  in  the  brain,   liver,   spleen,   and   kidneys.     In 


1 64  PELLAGRA 

those  assuming  a  chronic  condition  there  are  atrophic 
changes  that  simulate  those  changes  which  take  place 
following  albuminous  degeneration  of  cell  structures  re- 
sulting from  other  toxemias,  which  are  complete  atrophy, 
vacuolization,  degeneration  of  the  nucleus  characterized 
by  failure  to  take  the  basic  stains,  infiltration  of  pigment 
(brown  atrophy),  and  abiotrophy  or  partial  death  of  the 
cells. 

The  brain  especially  shows  this  condition,  there  being 
cell  degenerations  in  the  cortical  structure  of  the  brain  and 
lateral  and  posterior  columns  of  the  cord,  the  cell  degenera- 
tions here  mentioned.  WTien  the  nobler  cells  are  degener- 
ated or  completely  destroyed,  there  is  infiltration  of  con- 
nective-tissue stroma  to  supply  the  void  caused  by  the 
death  of  these  cells.  This  accounts  for  the  excessive 
amount  of  neurogHa  tissues  found  in  the  cortical  structure 
of  the  brain,  and  especially  in  the  lateral  and  posterior 
columns,  causing  the  pathologic  findings  in  this  disease  to 
simulate  locomotor  ataxia.  This  same  degenerative 
process  takes  place  not  only  in  the  brain,  but  in  the  kid- 
neys, Hver,  spleen,  and,  in  a  measure,  the  muscular  struc- 
tures, especially  the  heart,  as  in  one  case  there  was  a 
brown  atrophy  of  the  heart  musculature  much  simulating 
seniHty. 

Intestines. — In  two  of  these  cases  examined  the  intes- 
tines showed  conditions  which  were  somewhat  different 
from  reports  ordinarily  given  in  postmortem  findings. 
There  was  no  ulceration  and  but  little  change  in  the  ap- 
pearance of  the  intestinal  mucosa,  except  a  decided  thick- 
ening of  the  intestinal  walls  in  certain  areas.  The  micro- 
scopic examination  showed  that  this  thickening  was  due  to 


PATHOLOGY  AND  MORBID  ANATOMY  OF  PELLAGRA    165 

an  infiltration  of  fibrous  tissue,  the  musculature  having 
almost  entirely  disappeared.  The  mucosa  showed  but 
little  change  except  that  of  chronic  inflammation  char- 
acterized by  atrophy  and  disappearance  of  some  of  the 
columnar  cells,  and  infiltration  of  connective-tissue  stroma, 
which  stroma  had  numbers  of  foci  of  amyloid  degenera- 
tion. Whether  this  was  a  terminal  condition  resulting 
from  long-continued  illness  and  cachexia  which  might  have 
appeared  in  other  diseases,  Dr.  Thrash  could  not  say. 
His  observation  and  findings  led  him  to  believe  that  the  in- 
testinal and  stomach  disturbances  in  pellagra  are  secondary, 
resulting  from  nature's  effort  to  be  relieved  of  poisonings 
which  have  been  ingested,  and  which  have  resulted  from 
perverted  metabolism  and  various  atrophic  changes  of  all 
the  cell  structures  of  the  body. 

This  condition  must  be  relieved  by  the  emunctory 
organs,  and  they,  suffering  from  the  changes  mentioned, 
must  naturally  be  unable  to  perform  their  function,  and 
necessarily  the  alimentary  tract  would  have  extra  demands 
made  upon  it,  which  brin)2;s  on  the  train  of  symptoms  with 
which  we  are  so  familiar. 

Since  the  first  edition  of  this  book  was  published,  Dr. 
Thrash,  in  his  postmortem  work  at  Grady  Hospital,  has  per- 
formed a  number  of  autopsies  on  pellagrins,  and  his  later 
findings  present  no  notable  additions  to  his  previous  re- 
port. 

Passing  on  to  some  of  the  special  organs,  we  note  cer- 
tain morbid  conditions  obtaining  in  most  cases  of  pellagra, 
though  not  invariably,  and  some  of  these  changes  are  found 
nearly,  if  not  fully,  as  often  in  some  other  diseases. 

In  Lombardy,  edema  of  the  lungs,  pleurisy,  hyperemia, 


1 66  PELLAGRA 

emphysema,  and  pneumonia  were  frequently  found  in 
conjunction  with  pellagra.  Tuberculosis  was  rare,  though 
there  may  have  been  some  local  reason  for  this.  With 
us,  in  this  country,  tuberculosis  in  pellagrins  is  not  un- 
common. 

In  many  autopsies  brown  atrophy  of  the  heart  muscle 
has  been  observed,  also  frequent  softening  of  the  myocar- 
dium. Apart  from  this,  no  special  pellagrous  lesions  of 
the  heart  have  been  found. 

Lesions  of  the  liver  are  rather  common.  Sometimes 
it  is  small,  sometimes  it  is  large  and  friable,  and  brown 
atrophy  occurs.  In  29  autopsies  made  in  Italy  there  were 
7  cirrhoses  and  9  fatty  Uvers.  Sometimes  the  weight  of 
the  Hver  is  diminished  by  half.  Fatty  infiltration  is  often 
foimd,  and  congestion  or  granulofatty  degeneration. 

The  spleen  is  often  atrophied,  occasionally  hypertro- 
phied.  There  have  been  atrophied  spleens  noted  even  in 
typhoid  pellagra. 

Seldom  are  normal  kidneys  foimd  in  pellagrins.  They 
may  be  fatty,  atrophied,  cirrhotic,  or  cystic.  In  over 
haK  of  the  cases  the  weight  of  the  kidneys  is  diminished. 
Often  asymmetric  renal  sclerosis  is  present,  and  fatty  de- 
generation of  the  epithehum  of  the  tubules  is  found,  with 
or  without  interstitial  sclerosis. 

Fragility  of  the  bones  of  the  skeleton  has  been  noted  by 
several  observers.  This  fragility  is  supposed  to  depend  on 
the  eccentric  atrophy  of  the  compact  substance  with 
hypertrophy  of  the  medullary  substances,  and  has  been 
seemingly  demonstrated  by  the  microscope. 

The  main  skin  lesions,  as  described  by  Griffini,  consist  of 
marked  atrophy  of  the  stratimi  corneum,  copious  desquama- 


PATHOLOGY  AND  MORBID  ANATOMY  OF  PELLAGRA    167 

tion,  active  reproduction  in  the  Malpighian  reticulum,  and 
marked  sclerosis  of  the  vessels  of  the  papillary  layer  and 
the  derma. 

Pigmentary  degenerations  are  frequent,  some  of  which 
have  been  already  noted.  There  may  be  found  brown 
atrophy  of  the  heart,  pigmentation  of  the  liver  cells,  pig- 
mentation of  the  cerebral  vessels  and  of  the  spinal  and 
ganglionic  cells.  In  one  case  there  was  observed  a  general 
pigmentation  of  the  kidneys,  heart,  liver,  and  the  vessels 
of  the  brain. 

The  calcareous  degeneration  of  the  cerebral  vessels,  the 
thickening  of  the  membranes  of  the  brain  and  of  its  vessels, 
help  to  explain  the  frequent  psychic  disorders  which  almost 
invariably  accompany  pellagra. 

Also,  as  was  noted  by  Dr.  Thrash,  the  tendency  to  ather- 
oma and  precocious  senility  is  one  of  the  most  remarkable 
and  frequent  pathologic  changes  in  pellagra. 

The  pathology  has  by  no  means  been  worked  out  to  any 
definite  status  in  pellagra,  and  the  writer  has  been  forced 
to  gather  to  the  best  advantage  the  sometimes  divergent 
views  of  different  observers. 


CHAPTER  VII 

DIAGNOSIS,      COURSE      AND      PROGRESS,      AND 
PROGNOSIS   OF  PELLAGRA 

DIAGNOSIS 

After  so  much  has  been  written  concerning  the  clinical 
history  and  symptomatology  of  pellagra,  it  might  be  sur- 
mised that  to  diagnosticate  this  malady  would  be  an  easy 
matter.  This  is  so  in  t3;pic  manifestation,  as  it  is  in  typic 
manifestations  of  any  other  disease  entity. 

To  one  who  has  mastered  the  rudiments  of  diagnosis 
and  symptomatology,  such  diseases  as  variola,  measles, 
pertussis,  and  others  that  might  be  mentioned,  would 
offer  no  difficulty  were  their  pathognomonic  symptoms 
squarely  and  openly  exhibited. 

Thus,  with  pellagra,  when  the  erythema,  the  diarrhea, 
the  depressed  mentaHty,  and  the  nerve  pains  all  come  to- 
gether, the  diagnosis  is  thrust  on  the  physician  nolens 
volens.  The  very  many  atypic  cases,  however,  that  are  con- 
stantly cropping  up,  together  with  the  great  importance 
to  the  patient  of  an  early  diagnosis,  make  it  highly  essen- 
tial that  as  clear  a  diagnostic  picture  as  can  be  possibly 
drawn  should  be  presented  to  the  student  of  this  ofttimes 
puzzling  and  perplexing  malady. 

Viewing  it  in  perspective,  we  might  say  that  pellagra  pre- 
sented a  fourfold  syndrome,  the  presence  of  at  least  two 

168 


DIAGNOSIS  169 

units  of  which  would  be  necessary  in  order  to  make  a  diag- 
nosis. Ofttimes  two  are  not  quite  sufficient  for  a  positive 
diagnosis,  though  they  furnish  reasonable  certainty,  and  a 
tentative  diagnosis  is  justified.  Three  of  the  group  would 
make  out  quite  a  strong  case,  while  all  four  being  present 
would  render  the  diagnosis  an  absolute  certainty. 

According  to  the  views  of  the  writer,  who  has  given 
the  diagnosis  much  thought,  it  is  most  practicable  to  di- 
vide this  fourfold  diagnostic  syndrome  into  the  aspects  of 
gastro-intestinal,  dermal,  nervous,  and  psychic. 

It  should  be  remembered  that  there  is  no  definite  rule  as 
to  the  appearance  of  any  one  of  these  factors  at  any  spe- 
cific stage  of  the  disease.  For  instance,  there  may  have 
been  vague  gastro-intestinal  disturbances,  intermittent  in 
character  and  punctuated  by  periods  of  seemingly  perfect 
health.  Some  of  these  patients  may  have  suffered  from 
digestive  ailments  irrespective  of  the  pellagrous  onset  for 
a  number  of  years,  so  that  the  gastro-intestinal  symptoms 
may  seem  but  an  exacerbation  of  the  original  chronic 
trouble. 

^  In  a  not  inconsiderable  number  of  well-developed  cases 
of  pellagra,  if  care  is  taken  to  bring  it  out,  a  history  of 
slight,  almost  ephemeral,  "  sunburns,"  occurring  in  pre- 
vious springs  or  summers,  and  occasioning  neither  discom- 
fort nor  anxiety,  may  be  elicited.  In  many  pellagrins,  who 
perform  manual  labor,  men  who  work  in  the  open,  who 
are  exposed  to  the  vicissitudes  of  the  weather,  or  who 
handle  heavy  burdens;  women  who  perform  laborious 
household  duties,  who  scrub,  wash  dishes  and  clothes,  whose 
hands  are  much  in  hot  water,  and  whose  busy  feet  can  hardly 
keep  pace  with  the  constant  demands,  these  pay  but  scant 


lyo 


PELLAGRA 


attention  to  slight  erythemas,  dismissing  them  with  hardly 
a  passing  thought. 

Again,  the  dermal  manifestations  are  occasionally  late 
symptoms,  preceded  by  one  or  more  of  the  other  factors, 
and  only  needed  to  "  clinch  "  the  diagnosis.  However,  to 
wait  for  these  might  cause  the  patient  to  lose  precious  time 
— time  which  might  spell  the  difference  between  recovery 
and  death. 

The  manifold  symptoms  of  nerve-irritation,  appearing 
in  such  varied  guises,  may  be  easily  mistaken  for  many 
pathologic  conditions.  The  lightning  pains  of  tabes 
dorsalis;  the  disquieting  pangs  of  an  incipient  sciatica;  the 
reflex  neuralgias  from  previous  inflammatory  lesions;  the 
nervous  rumblings  from  an  ancient  gumma,  which  per- 
haps has  reposed  in  a  state  of  "  innocuous  desuetude  " 
for  years — such  as  these  may  mask  the  nervous  picture, 
and  also  cause  a  loss  of  valuable  time. 

In  the  psychic  factor  of  the  syndrome,  the  actual  be- 
ginning of  the  deviation  from  normal  is  probably  the  most 
difficult  of  all.  To  fairly  judge  temperamental  changes; 
to  estimate  slight  lapses  of  mental  poise;  to  differentiate 
between  a  dissatisfaction  or  a  slight  delusion,  or  between 
a  real  dislike  or  an  obsession  of  distrust;  to  estimate  the 
various  grades  of  unhappiness,  extending  from  hardly 
realized  mental  depression  to  deep  melancholia  or  positive 
forms  of  insanity — these,  too,  will  tax  to  the  uttermost 
the  skill  and  acumen  of  the  conscientious  student  of  this 
disease. 

Another  caution  may  appropriately  be  given  in  regard 
to  making  diagnosis  of  pellagra  on  insufficient  evidence. 

When  several  cases  have  appeared  in  some  community, 


DIAGNOSIS  171 

and  rumors  as  to  its  spread  are  rife,  there  is  sometimes  a 
tendency  to  diagnose  certain  illnesses  as  pellagra,  when  a 
more  careful  analysis  would  have  shown  the  obvious  errors. 

Within  the  last  six  months  the  writer  has  seen  diag- 
nosed as  pellagra  such  troubles  as  pyorrhea  alveolaris,  with 
sore  gums  and  irritated  tongue,  but  not  another  pellagrous 
symptom;  tuberculosis  of  the  intestines,  with  chronic  diar- 
rhea, but  no  erythema  or  psychasthenia;  aphthous  stoma- 
titis; marasmus  with  profound  anemia;  simple  melan- 
cholia; and  one  case  of  acute  mania,  where  there  was  ab- 
solutely no  excuse  for  such  a  mistake.  In  the  last-men- 
tioned instance  the  patient,  a  woman,  became  suddenly  and 
wildly  unbalanced  mentally.  There  was  no  diarrhea,  no 
history  of  indigestion,  no  erythema — nothing  but  a  dis- 
turbed mentality,  which  was  manifested  by  a  violent  de- 
lirium, and  which  later  on  ended  in  recovery. 

To  diagnose  such  cases  as  pellagra,  with  all  that  this 
diagnosis  entails,  is  unjust  to  the  patient,  and  liable  to 
reflect  seriously  on  the  attending  physician's  judgment. 

When  a  suspected  case  of  pellagra  presents  itself,  the 
history  should  be  carefully  taken  and  the  following  points 
noted : 

Has  there  been  a  history  of  indigestion  at  irregular  in- 
tervals without  apparent  cause?  Have  certain  articles 
recently  disagreed  that  formerly  agreed  with  the  patient? 
Has  the  patient  suffered  with  anorexia,  or  colicky  pains,  or 
diarrhea,  or  tenesmus?  Have  there  been  vague  or  active 
neuralgic  pains,  or  has  there  been  burning  of  the  hands, 
feet,  tongue,  or  buccal  membranes?  These  symptoms,  if 
present,  are  exceedingly  suspicious.  Has  there  been  a 
sense  of  malaise  or  weakness  in  the  preceding  spring,  or 


172 


PELLAGRA 


any  previous  springs  or  other  seasons  of  the  year?  If  this 
malaise  has  been  present  in  the  spring  or  summer,  has  it 
cleared  up  in  the  fall  and  winter?  Has  there  been  any 
"  sunburn  "  of  the  hands  or  face  or  neck,  or  has  there  been 
any  "  chapped  "  hands  or  lips,  which  later  on  seemed  well, 
but  left  for  a  while  a  tender  pink  surface?  Has  the  tongue 
been  sore,  or  have  there  been  any  "  mouth  ulcers  "  or  sore 
lips  or  cheeks?  Have  there  been  any  spells  of  "  blues  " 
or  periods  when  it  seemed  everything  went  wrong?  An- 
other question,  to  which  the  patient  cannot  give  a  correct 
answer,  is  regarding  any  change  of  disposition  or  feeling 
toward  those  near  and  dear.  It  has  been  often  found 
in  the  mental  perversion  of  pellagra  that  antipathies 
would  spring  up  against  those  closest  by  ties  of  blood  and 
companionship. 

Has  there  been  insomnia,  followed  by  an  intense  melan- 
choly? Has  fear  of  impending  danger  or  a  vague,  undefined 
sense  of  ill-being  brought  about  unhappy  days  and  "  nights 
devoid  of  ease  "?  Has  the  disposition  seemed  to  imdergo 
a  transformation,  so  that  a  formerly  cheerful  temperament 
has  lapsed  into  an  unhappy  and  morose  personab'ty? 
These  and  others  of  like  import  are  needed  to  bring  out 
the  saHent  points  in  the  diagnosis  of  pellagra. 

The  following  combined  S3anptoms  are  strongly  indicative 
of  a  positive  diagnosis  of  this  disease: 

A  symmetric  erythema  of  either  the  hands,  forearms, 
sides  of  neck  (rarely),  sides  of  nose  (rarely),  sides  of  fore- 
head (rarely),  or  the  dorsal  surfaces  of  both  feet.  The 
writer  recalls  no  case  of  pellagra  presenting  a  one-sided  skin 
lesion.  This  erythema  may  be  only  a  decided  blush,  not 
extending  below  the  epidermis,  but  it  must  be  symmetric, 


DIAGNOSIS  173 

scaly,  rather  rough,  and  present  a  distinct  Une  of  demarca- 
tion at  the  junction  with  the  healthy  skin.  Should  the 
erythema  be  more  pronounced,  showing  the  surface  of  a 
dull  pink,  as  if  it  had  been  "  baked  in  a  stove,"  should  the 
dorsal  surfaces  of  the  hands  appear  rather  "  shiny,"  pos- 
sibly merging  into  cracked  and  tender  interphalangeal 
spaces,  with  dry,  rough  and  scaly  feel,  and  dingy  brown  or 
black  palmar  surfaces,  this  would  constitute  a  formidable 
link  in  the  chain  of  evidence.  The  erythematous  patches 
on  other  parts  of  the  body  are  not  pathognomonic  unless 
in  conjunction  with  the  others  mentioned. 

Should  there  be  in  addition  to  this  erythema,  a  sore 
tongue  or  mouth,  cherry-red  and  tender  lips,  inflamed 
buccal  surfaces;  tongue  red  and  inflamed  on  the  top  or 
around  the  edges  and  denuded  of  epithelium,  aphthous 
ulcers  on  the  tongue  or  in  the  buccal  cavity,  with  dys- 
phagia either  from  soreness  or  "  nervousness,"  this  makes 
still  stronger  the  first  link  in  the  chain. 

Next  come  the  gastro-intestinal  symptoms,  to  which 
attention  has  been  called.  Should  the  patient  complain  of 
indigestion,  to  which  is  added  colicky  pains,  and  especially 
a  diarrhea,  apparently  causeless,  spasmodic,  tending  to 
involuntary  evacuations,  but  Httle  affected  by  what  is 
eaten  and  exceedingly  foul,  another  link  has  been  added  to 
the  pellagrous  bill  of  indictment. 

If,  in  addition  to  the  other  symptoms,  the  patient  should 
complain  of  shooting  pains  in  the  head  or  limbs;  of  pares- 
thesias, or  formications,  of  anesthetic  or  hj^Deresthetic 
areas;  of  intense  burning  of  the  mouth,  tongue,  hands  or  feet, 
or  any  other  part  of  the  body;  if  the  locomotion  was  un- 
steady or  impaired;  if  tremor  appeared  in  the  hands  or 


174  PELLAGRA 

tongue;  if  there  are  dizziness  with  the  eyes  closed  or  fear 
of  walking  in  the  dark  on  account  of  pedal  anesthesia,  still 
another  link  is  added. 

If,  in  corroboration  of  the  previous  symptoms,  there 
is  more  or  less  mental  depression,  verging  into  melan- 
choly, or  deeper  forms  of  psychic  abnormaUty;  if  the  tem- 
perament has  undergone  a  decided  change;  if  there  are 
doubts,  fears,  or  obsessions  where  there  were  formerly 
courage,  fortitude,  and  a  clear  vision  of  men  and  affairs; 
finally,  if  mental  failure  goes  apace  with  bodily  cachexia, 
the  picture  may  be  considered  complete,  the  Unks  in  the 
chain  of  pellagrous  evidence  uninterrupted,  doubts  may 
be  cast  aside,  and  the  diagnosis  may  be  made  with  entire 
assurance. 

Where  two  factors  in  this  s}mdrome  are  plainly  mani- 
fested, it  is  sometimes  perfectly  safe  to  make  a  diagnosis  of 
pellagra;  for  instance,  if  there  is  the  characteristic  erythema, 
coupled  with  an  indigestion  and  diarrhea.  The  nervous 
and  mental  symptoms  may  be  absent,  but  the  other  evi- 
dence may  be  sufficient.  Again,  there  may  be  present  a  sore 
mouth  and  tongue,  presenting  the  pellagrous  appearance, 
and  there  may  be  diarrhea  and  gastric  distress  in  evidence. 
In  such  an  instance,  while  the  presumptive  evidence  is 
strong  enough  to  warrant  putting  the  patient  under  treat- 
ment for  pellagra,  it  would  hardly  be  safe  to  make  a  posi- 
tive diagnosis  unless  either  the  erythema  or  nervous  or 
mental  symptoms  entered  in  evidence. 

The  writer  recently  diagnosed  a  case  upon  the  evidence 
of  slight  nervousness  and  a  mild  erythema.  The  other 
symptoms  were  absolutely  lacking,  but  the  erythema  was 
so  symmetric  and  characteristic  that  no  doubt  was  enter- 


DIAGNOSIS  175 

tained  as  to  other  symptoms  showing  up  later  on.  This 
expectation  was  reah'zed  about  two  months  later,  when  a 
colicky  diarrhea  set  in. 

Whether  or  not  a  physician  is  justified  in  making  a  diag- 
nosis of  pellagra  when  there  are  at  no  times  in  the  course 
of  the  illness  any  eruption,  is  an  open  question.  "  Pellagra 
sine  pellagra  "  is  a  term  that  is  odious  to  some,  impossible 
to  others,  and  ridiculous  to  a  few.  The  writer  feels  that 
it  is  possible  for  a  case  to  run  a  certain  course  without  any 
eruption,  but  he  would  be  exceedingly  chary  in  diagnos- 
ticating such  a  manifestation  unless  the  other  three  factors 
in  the  fourfold  syndromes  were  present  beyond  a  per  ad- 
venture. 

Scurvy,  leprosy,  beriberi,  and  syphilis  have  been  mis- 
taken for  pellagra,  but  should  be  easily  differentiated,  if 
care  is  taken. 

Chronic  mercurial  and  arsenic  poisoning  should  show  but 
little  difficulty  in  elimination  from  a  pellagrous  diagnosis. 

Some  food  or  occupation  poisonings  need  occasionally 
to  be  differentiated,  but  the  development  is  generally  dif- 
ferent and  the  pellagrous  syndrome  is  incomplete. 

Occasionally,  when  the  disease  assumes  a  typhoid  char- 
acter rather  early  in  its  course,  it  is  possible  to  confound  it 
with  one  of  the  infectious  diseases,  but  proper  analytic 
precautions  will  generally  suffice  to  clear  up  the  diagnosis. 

This  presentation  of  the  diagnostic  syndrome,  together 
with  the  other  aids,  as  previously  laid  down,  is  thought  by 
the  writer  to  be  full  enough  to  enable  any  thoughtful  ob- 
server to  recognize  pellagra. 


176  PELLAGRA 

COURSE  OF  THE  DISEASE 

A  part  of  this  has  been  already  covered  in  previous  chap- 
ters, but  some  of  the  features  require  additional  discussion. 

Pellagra  is  essentially  a  chronic  disease,  and  in  minor 
degrees  may  lurk  in  the  system  for  many  years.  One 
writer  has  expressed  the  behef  that  some  cases  have  lain 
latent  for  as  long  as  thirty  years,  only  to  take  on  an  added 
pathologic  impetus,  rapidly  proving  fatal.  Many  are 
the  reports  of  cases  lasting  five,  ten,  or  fifteen  years,  where 
the  recurrences  are  unmistakable.  These  intermittent 
pellagras  in  robust  persons,  where  the  habits  are  good 
and  the  environment  favorable,  may  run  an  almost  in- 
definite course,  permitting  the  sufferer  to  die  of  some  other 
ailment. 

In  the  majority  of  cases  the  first  manifestation  of  any 
sort  appears  in  the  spring  of  the  year,  and  either  disap- 
pears by  summer  or  fall,  or  decreases  in  severity.  In 
this  apparently  prodromal  stage  the  physician  is  seldom 
consulted,  or  if  so,  is  generally  consulted  for  some  other 
supposed  illness. 

Should  there  be  any  eruption,  it  is,  as  stated,  ascribed  to 
other  causes. 

The  writer  agrees  with  Dr.  Harris,  in  part,  as  to  many 
cases  of  chronic  "  dyspepsia,"  diarrhea,  or  obscure  debUity 
that  have  come  on  from  year  to  year,  not  quite  making 
an  invalid  of  the  sufferer,  but  preventing  a  full  adapta- 
tion to  all  the  requirements  of  active  life,  being,  in  reahty, 
instances  of  "  corn-bread  poisoning." 

In  the  opinion  of  most  of  the  students  of  pellagra,  it  is 
never  fatal  in  its  first  appearance,  and  will  either  uitermit 
or  remit  of  its  own  accord. 


COURSE  OF  THE  DISEASE  1 77 

It  is  in  the  second,  third,  or  later  recrudescence  that  the 
toxin  seems  to  have  gained  a  sufl&cient  momentum,  as  it 
were,  to  wreak  serious  damages.  It  is  then  that  the  differ- 
ent factors  in  the  syndrome  begin  to  assemble,  and  the  pic- 
ture of  pellagra  begins  to  assume  pathologic  shape. 

Pellagra  seems  essentially  a  disease  of  hot  weather. 
While  not  all  the  deaths  from  this  cause  occur  during  the 
heated  term,  the  vast  majority  do,  and  those  who  have 
had  experience  know  full  well  how  all  the  symptoms  of 
improvement  are  hastened  with  the  advent  of  cold  weather, 
and  even  the  fulminant  cases  seemingly  halted  in  their 
progress  toward  a  fatal  termination.  There  are,  of  course, 
exceptions  to  this,  but  they  are  few — not  more  than  the 
exceptions  in  other  chronic  seasonal  diseases. 

Having  passed  the  incubative  stage,  or  the  prodromal 
stage,  or  pellagra  of  the  first  degree,  as  denominated  by 
different  writers,  the  disease  assumes  the  second  stage,  or 
becomes,  as  Strambio  calls  it,  "  confirmed  pellagra." 

This  stage  in  the  course  shows  a  deepening  of  the  pre- 
vious symptoms  in  nearly  every  particular,  and,  unless 
checked,  generally  progresses  to  a  fatal  termination. 

The  following  quotation  from  Casenave,  written  over 
fifty  years  ago,  may  be  fitly  used  in  this  cormection,  as 
showing  the  difficulty  in  making  any  definite  classification 
of  the  course  of  pellagra: 

"  The  division  of  pellagra  into  commencing,  confirmed, 
and  inveterate  is  not  a  practical  one,  for  pellagra  may  be 
beyond  hope  from  its  commencement.  The  expressions 
period  and  degree,  which  convey  the  idea  of  certain  fixed 
symptoms  and  appearances,  are  not  adapted  to  the  descrip- 
tion of  a  disease  so  capricious.  The  term  degree  seems 
12 


178  PELLAGRA 

to  indicate  an  increasing  intensity,  while  the  second  or 
third  appearance  of  the  disease  may  be  less  severe  than  at 
first.  WTien  we  employ  these  terms,  therefore,  we  shall 
use  them  only  as  s^-mptoms  of  a  more  or  less  advanced 
step  of  the  disease,  for,  like  every  other  disease,  pellagra 
has  a  beginning,  a  progress,  and  a  termination." 

An  added  difficulty  in  following  the  course  of  pellagra 
lies  in  the  absence  of  well-marked  lines  of  demarcation 
between  the  different  so-called  stages.  The  intermittent 
may  imperceptibly  merge  into  the  corffirmed,  or  even  the 
apparently  confirmed  may  seem  to  improve  into  the  re- 
mittent or  even  the  intermittent  form. 

When  a  patient  reaches  this  stage,  however,  the  pellagra 
seldom  remains  stationar}^;  it  either  decidedly  improves 
or  the  reverse.  The  condition  has  become  so  intolerable 
that  efforts  are  made  for  relief,  so  that  either  amehoration 
of  the  trouble  ensues,  or  the  general  system  shows  an  in- 
abiht}^  to  cope  with  the  poison.  In  this  stage,  also,  the 
mental  abnormaHties  either  deepen  or  clear  up,  and  the 
various  psychoses  are  hable  to  become  confirmed. 

Should  the  progress  be  unfavorable,  a  general  cachexia 
may  set  in,  sapping  practically  every  organ  in  the  body. 
B}^  active  treatment  this  cachexia  may  be  halted  or  even 
driven  back,  but  when  pellagra  has  advanced  to  the  deeply 
cachectic  state,  -^^th  weakened  mentality,  it  may  safely  be 
assumed  that  trophoneuroses  have  taken  place,  in  which 
degenerations  and  scar  tissue  lie  behind  the  open  mani- 
festations. 

There  is  the  utmost  difference  between  the  progress 
of  pellagra  in  robust  indi^dduals.  v^ith  healthy  ancestry, 
good   habits,   hygienic   enviroimient,   financial   abihty   to 


f 


Unusual  pigmentation  in  pellagra.    Patient  died  ten  days  later.    (Courtesy 
of  Dr.  J.  W.  Babcock.) 


PROGNOSIS  179 

provide  nutritious  food,  and  intelligence  to  so  regulate  the 
mode  of  life  that  the  diseased  body  can  wage  a  strenuous 
fight  with  the  toxins  that  seek  to  destroy  it.  These  are 
the  cases  who  enable  the  physician  to  furnish  optimistic 
reports  concerning  pellagra,  and,  were  it  not  for  such  as 
these,  the  usual  progress  of  pellagra  would  be  most  dis- 
couraging. 

The  ravages  of  this  malady  in  some  of  the  congested  and 
poverty-stricken  localities  of  Europe  have  caused  many  to 
consider  it  a  disease  of  poverty.  This  is  an  error.  It  is  a 
disease  of  all  classes,  but  its  progress  among  the  physical 
or  mental  weaklings,  among  those  who  cannot  stop  long 
enough  in  the  battle  for  bread  to  deHberately  and  sys- 
tematically fight  this  monster — these  are  the  stricken  ones, 
who  yield  to  its  every  inroad  and  who  permit  its  rapid 
advance. 

We  may  sum  up  the  progress  of  pellagra  by  the  state- 
ment that  in  many  instances  its  course  is  most  erratic, 
but  that  in  normal  individuals  it  is  an  extremely  chronic 
disease,  and  that  a  duration  of  from  five  to  fifteen  or  even 
twenty-five  years  is  not  uncommon. 

PROGNOSIS 

It  may  be  emphasized  at  the  outset  that  pellagra  in  any 
degree,  however  seemingly  slight,  is  a  serious  disease. 
The  simplest  manifestation  is  a  proof  that  there  lurks  in 
the  system  a  subtle,  a  mysterious,  an  intangible  toxin,  one 
whose  lair  has  not  as  yet  been  located,  or  whose  intimate 
composition  been  understood.  We  are,  therefore,  in  a  sense, 
fighting  an  unseen  enemy,  and  until  this  enemy  is  forced 
into  the  open,  we  must  necessarily  rest  in  an  uncertainty. 


i8o  PELLAGRA 

Our  experience  with  pellagra  in  the  United  States  has 
been  too  limited  to  form  reliable  conclusions  as  to  its  mor- 
tality, most  of  our  few  statistics  being  based  on  asylum 
records.  It  is  natural  to  suppose  that  such  statistics  would 
be  very  high,  for  none  but  the  advanced  cases  are  sent 
to  asylums — cases  where  trophic  lesions  have  done  their 
destructive  work,  or  where  cachexias  have  sapped  the  scant 
vitality  of  the  invahd. 

Asyliun  statistics  to  date  give  the  startling  mortaHty  of 
67  per  cent.,  though  this  is  not  based  on  a  very  large 
number  of  cases. 

Statistics  on  non-asylum  cases  in  the  United  States  have 
not  been  collated  in  sufficient  numbers  to  furnish  any 
definite  or  reliable  information,  but  the  writer  feels  that 
there  is  much  reason  for  optimism  as  to  the  future  outlook 
of  the  situation,  and  Httle  excuse  for  the  attitude  of  wooden 
pessimism  assumed  by  some,  who  are  supposed  to  be  in  a 
position  to  speak  with  authority. 

Lombroso,  as  quoted  by  Dr.  Lavinder,  stated  that  in 
1883  there  were  treated  in  866  Itahan  civil  hospitals  6025 
pellagrins,  of  whom  923  died;  in  1884  there  were  treated 
in  993  hospitals  6944,  of  whom  780  died,  thus  giving,  in 
this  large  experience,  an  average  case  mortality  of  nearly 
13  per  cent. 

WoUenberg  (PubHc  Health  Reports,  July,  1909)  estimates 
from  reports  he  considers  fairly  reliable  a  total  of  55,029 
cases  in  Italy  in  1905,  with  a  total  mortality  of  2359,  a 
mortahty  of  a  Httle  over  4  per  cent.  Allowing  for  possible 
errors,  this  does  not  seem  such  a  very  gloomy  report. 

Early  cases,  those  recognized  before  cachexia  has  set  in, 
cases  in  the  intermittent  stage,  where  periods  of  seeming 


PROGNOSIS  l8i 

health  intervene  between  the  pellagrous  manifestations; 
cases  where  little  involvement  of  the  nerve-centers  is  ap- 
parent; cases  which  possess  enough  intelligence  and  perse- 
verance to  continue  treatment  for  a  long  time;  cases  with 
strong  ancestry,  without  syphilitic  or  other  hereditary 
taint — these  individuals  may  rightly  cherish  strong  hopes 
for  ultimate  and  complete  recovery. 

Other  factors  of  important  prognostic  import  relate  to 
habit  and  environment.  Those  who  are  not  willing  to 
regulate  their  daily  habits  strictly  along  hygienic  rules 
as  laid  down  by  the  medical  attendant  may  expect  un- 
satisfactory progress,  frequent  relapses,  and  probably  an 
imfavorable  termination.  Probably  the  most  dangerous 
indulgence  is  that  of  strong  drink.  Alcoholic  beverages, 
unless  in  the  smallest  and  most  attenuated  form,  are 
poisonous  to  pellagra,  and  it  is  wise  to  inform  the  patient 
of  this  fact  without  any  quibbles.  The  writer  would 
not  feel  justified  in  giving  any  "  steady  drinker  "  a  hopeful 
prognosis,  no  matter  how  early  in  the  disease  the  true  con- 
dition is  recognized. 

Again,  if  the  pellagrin  can  spend  the  heated  term  in  a 
cool  locaUty,  the  outlook  is  greatly  brightened.  Unfor- 
tunately this  is  impossible  in  many  instances. 

Speaking  generally,  it  might  be  said  that  the  earlier 
the  disease  is  diagnosed  and  treatment  begun,  the  more 
favorable  the  prognosis. 

The  amount  of  skin  involvement  is  not  a  fair  criterion 
of  the  gravity  of  the  invasion,  though  a  clearing  up  of 
these  lesions  is  to  quite  an  extent  an  index  of  improve- 
ment. 

The  chronic  types,  where  there  have  been  several  recru- 


l82  PELLAGRA 

descences,  but  neither  cachexia  nor  mental  involvement, 
may  be  considered  as  hopeful. 

Pellagra  being  ordinarily  an  afebrile  disease,  the  pres- 
ence of  fever,  particularly  if  decided  or  persistent,  may  be 
looked  on  with  grave  apprehension. 

The  nervous,  and  especially  the  psychic  symptoms 
furnish  more  reHable  indices  as  to  imderlying  trophic 
changes  or  degenerations.  Therefore,  where  marked  men- 
tal symptoms  supervene,  where  a  melancholy  or  a  settled 
gloom  pervades  the  temperament,  or,  worse  still,  if  demen- 
tia with  loss  of  reflexes  complicates  the  situation,  the  out- 
look is  correspondingly  darkened. 

The  writer  always  gives  a  guarded  prognosis  in  cases 
with  mental  involvement,  and  advises  his  readers  to  do 
likewise. 

Another  form  in  which  death  may  be  confidently  pre- 
dicted is  the  so-called  typhoid  pellagra.  When,  in  the 
course  of  the  pellagra,  there  appears  opisthotonos,  rigid- 
ity of  the  legs,  deHrium,  albuminous  urine,  with  ammoniac 
odor  of  the  perspiration,  tremors,  and  fibrillary  contrac- 
tions, accompanied  by  high  temperature,  the  end  is  not 
far  off. 

There  are  certain  compHcations  which  exert  a  decided 
bearing  on  the  ultimate  result;  among  these  are  malaria, 
intestinal  parasites,  nephritis,  acute  bronchitis,  pneumonia, 
bed-sores  (often  impossible  to  avoid),  tuberculosis  of  the 
bowels,  pregnancy,  or  any  acute  intercurrent  affections. 

Occasionally,  after  the  patient  seems  on  the  road  to 
recovery,  a  severe  recrudescence,  without  apparent  cause, 
greatly  clouds  the  prognosis. 

As  in  any  other  chronic  affection,  pellagra  renders  the 


PROGNOSIS  183 

body  more  vulnerable  to  infections  or  epidemic  diseases. 
The  physician  should  always  bear  in  mind  that  in  pellagra 
we  are  treating  a  disease  entity,  the  etiologic  foundation 
of  which  is  not  settled,  and  until  this  "  consummation  de- 
voutly to  be  hoped  "  is  realized,  we  should  in  every  case 
be  exceedingly  careful  as  to  promises  of  recovery.  In  ad- 
dition, remembering  its  seasonal  character,  a  full  year, 
unbroken  by  any  pellagrous  symptoms,  should  elapse  be- 
fore an  opinion  as  to  cure  should  be  expressed.  Especially 
is  it  to  be  desired  that  the  patient  should  pass  the  following 
spring  and  early  summer  with  no  sign  of  a  recrudescence. 
Should  this  fortunate  state  of  affairs  take  place,  where 
the  skin  lesions  have  disappeared,  where  the  digestion 
seems  normal  and  the  diarrhea  has  abated;  should  the 
drooping  spirits  regain  their  wonted  vivacity,  and  the 
wasted  body  put  on  again  a  Hberal  amount  of  adipose 
tissue,  and  should  this  improvement  last  for  a  year  or 
more,  the  pellagra  may  be  considered  cured,  and  the  pa- 
tient may  reasonably  indulge  in  the  hope  that  the  mysteri- 
ous poison  has  departed  never  to  return. 


CHAPTER  VIII 

THE  TREATMENT  OF  PELLAGRA— A  DISCUSSION 
OF  DIFFERENT  METHODS 

It  is  admitted  at  the  outset  that  a  specific  treatment  for 
pellagra  has  not  been  found. 

When,  in  any  disease,  a  multiplicity  of  remedies  are 
laid  down,  it  is  proof  positive  that  one  sovereign  remedy 
has  not  been  discovered.  This  is  unfortunately  true  to  a 
degree  in  pellagra,  but  the  accumulated  experience  of  many 
students  with  methods,  empiric  and  otherwise,  has  not 
been  barren  of  results,  so  we  feel  that  the  therapy  of  this 
malady  has  been  removed  from  the  realm  of  mere  guess- 
work, and  that  many  of  the  s3nnptoms  we  can  attack  with 
a  feeling  of  confidence  bom  of  past  successes. 

In  this  chapter  some  of  the  views  of  different  investiga- 
tors will  be  discussed,  but  the  writer  will  give  a  full  ac- 
count of  the  therapeutic  procedures  which  (in  his  and  the 
experience  of  those  whose  opinions  he  values)  have  yielded 
the  best  results. 

Lombroso  was  the  first  to  formulate  any  definite  treat- 
ment, and  some  remarks  made  shortly  before  his  death 
had  a  prophetic  ring.  He  said,  "  The  therapy  of  this 
disease,  which  was  at  first  desperate,  and  could  be  summed 
up  in  baths  barren  of  result,  can  now  be  undertaken  more 
confidently  and  rationally,  as  the  treatment  of  a  chronic 
intoxication,  analogous  to  alcoholism  or  morphinism,  and 

184 


DIFFERENT  METHODS  OF  TREATMENT  185 

curable  by  antidotes,  when  the  use  of  the  toxic  material 
has  been  suspended.  These  antidotes  are  probably  to  be 
found  in  arsenic  and  chlorid  of  sodium." 

The  teaching  of  Lombroso  has  met  with  deserved  re- 
spect, and  many  of  his  ideas  have  formed  the  basis  of  the 
present  therapy.  To  attempt  to  cover  this  subject  without 
a  review  of  the  measures  recommended  by  him  would 
render  the  chapter  incomplete. 

He  recommended  a  liberal  diet,  including  a  full  allow- 
ance of  meat,  though  in  the  well  nourished  he  did  not  con- 
sider it  so  necessary  to  push  the  feeding.  He  also  recom- 
mended baths  and  cold  douches  for  the  paretic  state,  the 
chronic  skin  lesions,  and  the  neuritis  manifested  by  burn- 
ing sensations.  In  those,  however,  where  a  repugnance 
to  baths  was  manifested  he  did  not  insist  on  hydrotherapy. 
He  did  not  favor  iron,  for  he  seldom  saw  benefit  arise  from 
its  use,  while  he  often  saw  it  exert  an  unfavorable  in- 
fluence on  the  gastro-intestinal  s3niiptoms.  Acetate  of 
lead  he  tried  out,  finding  it  of  no  avail  except  in  pellagra 
of  the  aged.  In  typhoid  pellagra  he  obtained  no  benefit 
from  any  procedures. 

Finally,  Lombroso  thought  of  arsenic,  and,  after  experi- 
menting with  it  for  a  while,  he  came  to  the  conclusion 
that  in  it  he  had  found  a  most  valuable  remedy — not  an 
absolute  specific,  but  a  remedy  that  acts  somewhat  as  an 
antidote.  In  this  particular  he  compared  the  action  of 
arsenic  to  that  of  opium  in  alcoholism  or  mercury  and  the 
iodids  in  syphilis.  Sodium  chlorid  he  also  used  with 
some  satisfaction,  but  seemed  to  think  its  best  effect  was  in 
children.  In  using  this  drug  (arsenic)  he  either  admin- 
istered Fowler's  solution,  beginning  in  5 -drop  doses  and 


1 86  PELLAGRA 

increasing  to  the  physiologic  Hmit,  or  arsenous  acid 
(arsenic  trioxid),  dissolved  in  slightly  alcoholized  water  in 
doses  of  4V  mg.  up  to  the  point  of  tolerance.  When  the 
well-known  physiologic  effects  appeared  he  would  suspend 
the  drug  for  a  few  days,  begin  with  the  minimal  dose,  and 
gradually  work  upward  again. 

Among  the  types  which  he  thought  arsenic  benefited 
were  cases  with  marked  marasmus;  cases  with  incipient 
paresis;  cases  badly  run  down  as  a  result  of  sitophobia; 
cases  with  vague  mania,  but  not  systematized  deHrium; 
cases  in  aged  people,  if  not  too  senile. 

Among  the  class  of  cases  which  derived  little  benefit  from 
arsenic  were  children  and  robust  cases;  cases  with  systemat- 
ized delirium;  cases  with  mental  alienation  of  extreme 
chronicity;  cases  compKcated  by  lobar  pneumonia,  tuber- 
culosis, nephritis,  or  severe  and  oft-recurring  vertigo. 

Among  the  symptomatic  remedies  of  his  armamen- 
tarium were  calomel,  bismuth,  castor  oil,  opium,  tannin, 
and  chlorate  of  potash.  He  also  advocated  strychnin  and 
faradism,  and  in  restless  or  maniacal  cases  he  used  opiurd, 
chloral,  or  paraldehyd  as  hypnotics. 

While  he  claimed  that  even  empirically  arsenic  had 
proved  its  beneficial  effect,  he  also  claimed  that  rationally 
it  could  be  prescribed  on  the  grounds  of  its  tonic  and 
"  alterative  "  effect  on  the  heart,  skin,  and  nervous  system, 
besides  its  antifermentative  power  in  the  alimentary 
tract. 

His  methods — ^hygienic,  dietetic,  and  medicinal — have 
served  in  many  ways  as  a  beacon  hght,  which  stUl  casts 
its  rays  on  the  therapeutics  of  the  present  time. 

To  review  all  the  literature  to  date  advocating  coimtless 


DIFFERENT  METHODS  OF  TREATMENT  187 

remedies,  some  of  them  more  bizarre  than  reasonable,  would 
demand  a  useless  expenditure  of  the  reader's  time.  Such 
will  not  be  attempted,  but  some  of  the  contemporaneous 
literature  will  be  abstracted  in  order  to  show  that  the  rank 
and  file  of  the  medical  profession  have  not  slept  over  this 
problem. 

The  first  comparatively  non-toxic  preparation  of  arsenic 
was  atoxyl,  probably  first  used  by  Babes,  and  it  seemed  to 
give  quite  satisfactory  results.  Following  atoxyl  came 
soamin  and  arsacetin,  all  trade  names  for  sodium  arsanilate, 
and  containing  from  22  to  26  per  cent,  of  this  drug. 

It  would  appear  that  the  arsenic  in  these  preparations 
is  liberated  very  slowly  in  the  system,  thus  obtaining  the 
wished-for  therapeutic  effect  minus  the  toxic.  Atoxyl 
and  the  other  trade  preparations  of  its  class  were  claimed 
to  exert  only  about  the  fortieth  toxic  effect  of  arsenic 
trioxid,  but  in  several  instances  unfavorable  effects  were 
noticed,  among  others  degeneration  of  the  optic  nerve, 
resulting  in  blindness.  Koch,  who  was  at  first  a  strong 
advocate  of  atoxyl,  after  getting  several  cases  of  blindness 
from  its  use,  and  feeling  that  small  doses  were  valueless, 
gave  it  up. 

Those  who  used  this  preparation  began  in  doses  of 
^  to  3  gr.,  given  hypodermically  every  alternate  day, 
and  increased  until  the  single  dose  reached  as  much  as 
10  gr. 

Arsacetin,  or  sodium  acetyl  arsanilate,  was  much  more 
soluble  than  atoxyl,  would  stand  heating  so  that  it  could 
be  sterilized,  and  was  given  in  doses  ranging  from  i  to  7  gr. 
hypodermically. 

Babes  thought  well  of  atoxyl  from  his  experience  in 


1 88  PELLAGRA 

Roumania,  while  Wamock,  who  used  it  in  the  asylum  at 
Cairo,  Egypt,  was  at  first  quite  enthusiastic  over  his  results. 
Later  reports,  however,  were  not  so  unanimous  in  its 
praise,  and  in  one  of  his  papers  Wamock  wrote,  "  It  may 
be  said  that  the  value  of  atoxyl  in  the  advanced  stages 
of  pellagra,  such  as  are  met  with  in  this  asylum,  has  not 
been  demonstrated." 

Among  American  observers,  who  have  not  been  pleased 
with  atoxyl  after  extensive  trial,  are  Wood,  of  Wilmington, 
and  Babcock,  of  Columbia. 

Soamin  is  still  being  used  in  some  quarters  with  satisfac- 
tion, but  the  writer  does  not  believe  that  atoxyl  or  arsacetin 
is  at  present  being  administered  to  any  great  extent. 

Among  the  next  therapeutic  procedures  to  attract  at- 
tention was  transfusion  of  blood,  as  advocated  by  Cole  and 
Winthrop,  of  Mobile,  who  were  the  first  in  this  country 
to  champion  it  successfully. 

These  investigators  proceeded  upon  the  assumption  that : 

"Pellagra  is  an  intoxication,  the  toxic  principles  exist- 
ing in  the  blood  of  pellagrins. 

"  The  production  of  pellagrous  symptoms  by  the  injec- 
tion of  blood  from  pellagrins,  the  definite  precipitative, 
hemolytic,  and  antitoxic  action  of  the  serum,  the  artificial 
immunity  produced  in  animals,  and  the  immunity  acquired 
in  patients  recovered  from  pellagra,  are  all  suggestive  of  a 
serum  treatment  in  the  solution  of  the  pellagra  problem. 

"  Antonini  and  Marianni  used  pellagrous  serum  hypo- 
dermically  with  apparently  good  effects,  so  much  so  that 
Lombroso,  in  a  manner,  indorsed  their  efforts." 

Cole  and  Winthrop,  belie\Tng  that  the  blood  of  a  healed 
pellagrin  possessed  all  the  curative  powers  of  the  serum, 


DIFFERENT  METHODS  OF  TREATMENT  189 

besides  having  a  tendency  to  improve  the  anemia  in  severe 
cases,  transfused  quite  a  number,  with  seeming  remarkable 
effects  in  some  of  the  cases. 

They  report  the  following  conclusions: 

"  (i)  In  certain  severe  cases  of  pellagra  resisting  all 
forms  of  medical  treatment  transfusion  has  been  followed 
by  recovery  with  no  relapse. 

"  (2)  The  patients  recovering  showed  marked  improve- 
ment from  the  first;  in  the  fatal  cases  there  was  no  benefit 
from  transfusion. 

"  (3)  Transfusion  is  of  undoubted  value  in  certain  severe 
and  apparently  hopeless  cases,  but  without  a  thorough 
knowledge  of  the  technic  of  transfusion,  and  without  a 
careful  selection  of  the  cases  and  donors,  it  will  be  brought 
into  an  undeserved  ill  repute." 

Possibly,  for  the  reasons  mentioned,  this  operation  has 
fallen  somewhat  into  disrepute,  and  perhaps  undeserv- 
edly. It  must  be  admitted  that  some  apparently  hopeless 
cases  have  suddenly  showed  marked  improvement  after 
transfusion,  and  the  writer  trusts  that,  with  the  improved 
technic,  etc.,  as  advocated  by  these  gentlemen,  transfusion 
may  still  hold  a  worthy  place  in  the  treatment  of  certain 
selected  cases.  This  procedure  must  always  be  employed 
by  a  careful  surgeon  and  under  favorable  surroundings, 
otherwise  it  will  prove  disastrous. 

At  present,  few,  if  any,  advocate  transfusion,  except  as  a 
dernier  ressort. 

Dr.  A.  C.  Cudd,  of  Spartanburg,  S.  C,  has  reported  three 
appendicostomies  with  irrigation  of  the  colon  for  pellagra, 
and  feels  that  decided  improvement  was  obtained  in  two 
of  them. 


I  go  PELLAGRA 

Another  surgeon,  whose  name  has  escaped  the  writer, 
has  advocated  cecostomy  and  irrigation  in  pellagra. 

These  radical  surgical  operations,  while  they  may  aid  in 
the  elimination  of  toxins  from  the  intestines,  must  necessar- 
ily be  limited  in  their  application,  and  will  probably  not  be 
used  to  any  great  extent. 

The  idea  that  the  colon  is  the  most  frequent  habitat  of 
"  pellagrous  germs,"  and  that  its  thorough  irrigation  will 
aid  in  the  systemic  elimination,  is  not  a  new  departure,  but 
has  been  frequently  mentioned  by  the  older  writers.  It 
may  be  stated  as  a  general  principle,  however,  that  any 
agencies  assisting  in  cleansing  a  filthy  colon  exercises  to 
some  degree  a  helpful  influence  on  pellagra. 

Drainage  of  the  gall-bladder  has  been  advocated  and  per- 
formed in  Atlanta  quite  recently,  but  the  cases  have  been 
too  few  and  the  time  too  short  since  the  operations  to  arrive 
at  any  definite  conclusions  as  to  their  effect  on  the  disease. 

Along  with  many  other  systemic  infections  for  which  sal- 
varsan  has  been  employed  is  pellagra.  It  has  almost  be- 
come the  custom  in  some  quarters,  when  other  remedies 
fail,  to  use  salvarsan  empirically,  hoping  that  in  some  un- 
explained way  benefit  might  ensue.  Dr.  E.  H.  Martin,  of 
Hot  Springs,  Ark.,  strongly  advocates  both  salvarsan  and 
neosalvarsan,  claiming  the  former  to  be  35  to  50  per  cent, 
more  curative  than  the  latter. 

The  writer  has  seen  it  injected  in  several  cases,  and  has 
reports  on  over  eighty  instances,  where  it  was  employed  in 
practically  every  stage  of  pellagra,  from  the  mild  to  the 
t}^hoid,  and  the  consensus  of  opinion  is  that  it  is  useless, 
unless  syphilis  enters  as  a  complication. 

No  other  special  surgical  treatment  has  been  suggested. 


DIFFERENT  METHODS  OF  TREATMENT  191 

We  will  now  take  up  the  general  treatment  of  pellagra  in 
its  different  phases:  First,  the  treatment  of  the  disease  as 
an  entity;  second,  treatment  of  the  special  symptoms,  of 
which  there  are  many,  and  of  the  complications,  of  which 
the  same  may  be  said. 

The  general  treatment  naturally  divides  itself  into:  (i) 
dietetic;  (2)  hygienic;  (3)  hydrotherapeutic ;  (4)  medicinal; 
(5)  cHmatic. 

Dietetic  Treatment.— Until  the  theory  regarding  the  eti- 
ology of  pellagra  is  clearly  settled,  and  the  present  zeist 
views  as  to  some  products  of  spoiled  corn  being  responsible 
is  exploded,  it  would  appear  the  part  of  wisdom  to  give  our 
patients  the  benefit  of  the  doubt  by  excluding  from  the 
dietary,  so  far  as  possible,  all  articles  of  food  made  from 
corn  or  corn  products.  We  say  "  so  far  as  possible,"  for, 
as  has  been  previously  mentioned,  there  are  so  many  adul- 
terated food  products  on  the  market  in  which  some  deriv- 
ative of  corn  is  the  adulterant  that  we  cannot  always  be 
sure  that  corn  is  really  absent  from  our  daily  food  or  drink. 

This  would  also  apply  forcibly  to  the  dietaries  of  various 
institutions,  especially  those  for  nervous  and  mental  in- 
valids. 

In  the  early  manifestations  of  diarrhea,  this  symptom 
being  in  the  main  compensatory,  a  restricted  diet  has  but 
little  influence,  though,  of  course,  the  ordinary  care  as  to 
food  with  a  large  amount  of  irritating  residue  should  be 
noted.  This  applies  only  to  the  early  diarrhea  before  in- 
flammatory changes  of  the  intestinal  mucosa  have  occurred. 

Pellagra  being  both  chronic  and  exhausting,  active  sup- 
portive measures  are  indicated  from  the  very  outset. 
Every  patient  with  pellagra,  no  matter  how  light  it  appears, 


192  PELLAGRA 

may  be  considered  to  have  entered  into  a  long  and  taxing 
battle,  and  his  daily  caloric  requirements  should  be  guarded 
most  zealously. 

Along  this  line  should  be  stressed  the  caution  that  when 
certain  articles  of  food  of  which  the  pellagrin  is  fond  are 
prohibited,  the  medical  attendant  should  see  to  it  that 
these  articles  are  replaced  by  something  else  with  an  equal 
caloric  value,  or  the  nutrition  will  seriously  suffer. 

The  writer  has  observed  a  number  of  patients  where  one 
article  after  another  has  been  eliminated  from  the  daily 
dietSLTy  without  being  replaced  specifically,  until  the 
patient  was  not  ingesting  enough  for  an  infant  in  arms. 

The  diet  should  be  easily  assimilable,  highly  nutritious, 
and  it  might  be  added  that  p)ellagrins  seem  to  bear  spe- 
cially well  the  flesh  proteins. 

It  has  been  the  experience  of  the  writer  that  all  along 
through  the  course  of  the  disease  meats  are  well  borne,  and, 
even  in  those  conditions  where  there  is  much  active  gastro- 
intestinal irritation,  they  agree  better  than  in  a  Hke  amount 
of  irritation  from  other  causes.  Tender  broiled  steak  or 
roast  beef,  lamb,  or  other  roast  meats  may  be  given  twice 
daily,  or,  if  the  mouth  is  too  sore  to  chew,  either  the  scraped 
beef  or  that  ground  in  a  sausage  mill  may  be  served.  This 
also  applies  to  the  white  meats,  and,  if  the  suggested  grind- 
ing of  the  meat  is  carried  out,  it  is  as  little  irritating  as 
possible  to  the  inflamed  buccal  membrane. 

As  a  sample  diet  in  Italy  may  be  mentioned  that  at  the 
Locanda  Sanitaria  at  Bagnolo  Mella.  It  is  as  follows: 
First  meal,  meat  broth  and  coffee  and  milk,  each  on  alter- 
nate days,  with  150  grams  of  bread.  Second  meal,  one 
Kter  of  soup  made  of  macaroni,  100  grams  of  vegetables, 


DIFFERENT  METHODS  OF  TREATMENT  193 

100  grams  meat  stock  and  condiments;  boiled  meat,  200 
grams;  vegetables,  50  grams;  bread,  300  grams;  wine,  200 
grams.  Third  meal,  one-half  liter  of  soup  made  of  rice, 
50  grams;  vegetables,  50  grams;  meat  stock  and  condiments, 
100  grams;  vegetables,  50  grams;  and  wine,  200  grams. 
This  diet  is  modified  in  many  ways  to  suit  individual  tastes 
and  idiosyncrasies,  and  reduced  in  quantity  for  children 
under  twelve  years  of  age. 

Eggs  are  generally  permissible,  though,  if  there  is  a 
flatulent  tendency,  it  is  well  to  give  only  the  whites.  The 
albumen  of  raw  eggs  may  be  prepared  in  various  ways, 
limited  only  by  the  ingenuity  of  the  nurse,  being  flavored 
with  orange,  lemon,  grape,  or  other  juices,  and  when  pre- 
pared this  way  seldom  disagree.  These  egg-albumens  are 
most  valuable  in  the  exhausted  typhoid  conditions,  and  may 
be  administered  early  and  often. 

Sweet  milk  is  valuable  when  it  agrees,  but,  unfortunately, 
many  pellagrins  show  an  idios5nicrasy  against  it.  Flatu- 
lence frequently  follows  its  ingestion,  and  in  many  patients 
the  stomachs  furnish  enough  rennin  to  promptly  coagulate 
the  milk,  but  are  tardy  in  disintegrating  the  curds,  so  there 
is  present  a  sense  of  weight  and  discomfort  in  the  epigas- 
trium. Peptonizing  the  milk  usually  obviates  this,  but  few 
pellagrins  rehsh  peptonized  milk. 

One  highly  esteemed  confrere  recommends  for  pellagra 
forced  feeding,  consisting  of  six  raw  eggs  and  three  quarts 
of  sweet  milk  daily,  both  being  increased  until  at  least  a 
gallon  of  milk  and  ten  or  twelve  raw  eggs  are  consumed 
in  the  twenty-four  hours.  This  would  be  practicable  in 
a  not  very  large  proportion  of  cases. 

Buttermilk  is  a  most  useful  article  of  diet,  seldom  up- 

13 


194  PELLAGRA 

setting  the  stomach  or  intestines.  The  artificially  soured 
milk,  or  lacteal  champagne,  containing  all  the  fat,  is  often 
not  only  well  borne,  but  acts  as  an  appetizer. 

Where  constipation  is  in  evidence,  oatmeal,  tender  vege- 
tables in  puree  form,  thoroughly  baked  Irish — not  sweet — 
potatoes,  or  cereals  with  but  little  sugar  will  aid  the  peris- 
talsis of  the  intestines. 

Later  on  in  the  course  of  the  disease,  when  inflammatory 
lesions  have  set  up  in  the  intestines,  or  a  chronic  gastritis 
complicates  the  situation,  the  diet  should  be  suited  to  the 
condition,  remembering,  though,  that  to  some  extent  the 
gastro-intestinal  tract  will  bear  more  in  pellagra  than  when 
similarly  inflamed  from  other  diseases. 

Barley-gruel,  rice-water,  the  hghter  cereals,  thick  broths 
with  scant  condiments,  malted  milk  and  egg,  dry  meat 
powders,  dry  albuminized  powders,  with  butter  up  to  the 
patient's  ability  to  eat — this  is  a  general  summary  of  the 
later  diet. 

Olive  oil,  in  |-  or  i-ounce  doses  at  intervals,  will  often 
help  the  abdominal  cramps,  while  the  addition  of  an  egg  to 
each  portion  of  the  olive  oil  will  greatly  swell  the  daily 
calories. 

The  following  dietary  is  recommended  by  Dr.  Joseph 
Goldberger  in  his  last  report,  January  15,  1915,  and  coin- 
cides to  a  remarkable  extent  with  that  advocated  by  the 
writer  as  far  back  as  1909: 

"Milk. — Fresh  milk  alone  or  in  alternation  with  butter- 
milk should  be  given  freely.  It  is  probably  the  most  valu- 
able single  food,  and  adults  should  be  urged  to  take  not  less 
than  i^  to  2  pints  in  the  twenty-four  hours. 

"Eggs. — Fresh  eggs  should  be  allowed  freely.     In  addi- 


DIFFERENT  METHODS  OF  TREATMENT  195 

tion  to  the  milk  and  meat,  an  adult  should  take  not  less 
than  four  eggs  a  day.  In  certain  of  the  severer  forms  it 
may  be  necessary  to  give  the  eggs  in  the  form  of  albumen- 
water,  preferably  with  orange  or  lemon  juice. 

"Meat. — The  meat  should  be  fresh  lean  meat.  Whether 
all  fresh  meats  are  equally  valuable  in  treatment  we  do  not 
know;  future  studies  will  have  to  determine  this.  Our  ex- 
perience has  been  with  beef  alone.  This  may  be  served  as 
scraped  beef,  as  a  roast,  or  as  steak.  Where  mastication  is 
painful,  meat _ juice  may  be  given  instead.  An  adult  should 
be  urged  to  take  at  least  a  half  pound  of  lean  meat  a  day  in 
addition  to  the  milk,  eggs,  and  legumes.  It  may  be  neces- 
sary in  some  instances  to  work  up  gradually  to  the  point 
where  these  quantities  can  be  taken. 

''Legumes. — We  have  been  much  impressed  with  the 
favorable  results  following  the  use  of  beans  and  peas  alone. 
The  beans  and  peas  should  be  fresh  or  dried,  not  canned. 
The  palatable  pea  or  bean  soup  should  be  prepared  and 
should  be  given  freely.  In  addition  to  or  in  alternation 
with  the  soup  the  beans  or  peas  should  be  served  and  eaten 
in  any  one  of  the  other  well-known  forms. 

"In  cases  presenting  marked  gastro-intestinal  symptoms, 
the  diet  of  the  patient  may  be  limited  to  the  foregoing 
articles.  It  may  here  be  emphasized  that  diarrhea  is  no 
contraindication  to  the  full  feeding. 

"In  cases  presenting  only  moderate  or  no  gastro-intestinal 
symptoms  there  may  be  added,  in  restricted  amounts,  oat- 
meal, rice,  and  barley  as  cereals,  potatoes  and  onions  as 
fresh  vegetables,  fresh  or  dried  (not  canned)  fruits,  and 
wheat  or  rye  bread  or  biscuits. 

"As  long  as  symptoms  of  pellagra  are  perceptible  we  pre- 


196  PELLAGRA 

fer  to  exclude  all  corn  products;  not  that  corn  is  not  a 
wholesome  and  nutritious  food,  but  because  the  occurrence 
of  pellagra  is  commonly,  though  by  no  means  exclusively, 
associated  with  the  consumption  of  a  diet  in  which  corn 
forms  a  disproportionately  large  part.  Similarly,  a  reduc- 
tion in  the  amount  of  other  carbohydraceous  articles,  such 
as  the  newer  cereal  breakfast  foods,  molasses,  jams,  or 
starch,  should,  we  think,  be  ordered,  if  on  analysis  of  the 
patient's  prepellagrinous  dietary  some  such  articles  or  com- 
bination of  articles  appear  to  have  formed  a  very  conspicu- 
ous proportion  of  the  diet. 

"After  all  S5miptoms  of  pellagra  have  disappeared,  com 
and  other  starchy  foods  in  moderation  and  guarded  with 
an  abundance  of  milk,  meat,  or  legumes,  and,  preferably, 
with  all  of  these,  may  unhesitatingly  be  allowed." 

The  experience  of  the  writer  has  rendered  him  chary  in 
the  use  of  alcohol  in  pellagra.  It  would  appear  that  the 
possible  fuel  and  food  value  of  alcohol  is  more  than  counter- 
balanced by  its  malign  effect  on  the  gastro-intestinal 
mucosa,  as  has  been  noted  in  a  number  of  instances  where 
this  agent  was  added  to  the  dietary  in  apparently  conva- 
lescing cases.  In  exceptional  cases,  when  whisky  or  brandy 
are  deemed  necessary  by  the  physician,  they  should  be  well 
diluted,  and  be  given  as  milk-punch,  egg-nog,  or  with  grape- 
juice  or  lemonade. 

Practically  the  same  may  be  said  concerning  the  alco- 
holic proprietary  food  preparations.  As  an  aid  to  the  daily 
regimen  or  to  tide  over  some  dietetic  emergencies  some  of 
them  are  useful. 

During  intercurrent  attacks  of  vomiting,  when  no  food 
can  be  retained,  or  where  more  solid  nourishment  is  omitted 


DIFFERENT  METHODS  OF  TREATMENT  197 

during  the  night,  calling  for  some  slight  stimulant,  they 
fill  an  indication,  but  as  a  dependence  to  supply  daily  caloric 
requirements  they  are  a  "  delusion  and  a  snare."  To 
furnish  sufficient  calories  with  these  preparations  alone 
would  keep  the  patient  in  a  state  of  alcoholic  coma  plus 
all  the  resultant  evils  reflected  on  the  whole  ahmentary 
tract.  This  is  no  imaginary  picture,  but  has  been  impressed 
on  the  writer  by  observation  of  some  melancholy  in- 
stances, where  zeal  had  outstripped  discretion,  and  where 
evidences  of  alcoholic  intoxication  were  thoughtlessly 
attributed  to  other  causes. 

,  To  wisely  adjust  the  daily  regimen  to  each  individual 
case,  respecting  idiosyncrasies,  likes  and  dislikes  is  no  easy 
task,  and  will  require  both  time  and  patience.  The  prob- 
lem of  the  bodily  up-keep  in  pellagra  is  of  basic  importance, 
and  should  never  be  lost  sight  of  from  the  beginning  of 
the  management.  Its  successful  solution  will  in  most  in- 
stances decide  the  ultimate  prognosis,  marking  the  differ- 
ence between  recovery  and  death. 

Hygienic  Treatment. — In  no  other  chronic  or  exhaustive 
disease  is  there  a  greater  necessity  for  hygienic  habits  than 
pellagra.  At  best  the  patient  has  an  up-hill  fight,  and  both 
body  and  mind  need  every  aid  that  can  be  afforded. 

One  of  the  first  hygienic  considerations  is  rest.  As  far 
as  practicable  this  should  be  enforced,  while  any  evidences 
of  bodily  weakness,  nervous  irritation,  or  mental  instabil- 
ity are  evident.  The  patient  should  be  put  to  bed  for  a 
while,  and  every  disquieting  factor  removed.  Good  ven- 
tilation, not  too  much  light,  freedom  from  disturbing 
noises,  cheerful  companionship,  and  all  that  train  of  help- 
ful influences  that  prevent  confinement  being  so  irksome 


1 98  PELLAGR.\ 

are  indicated.  In  those  cases  where  it  is  not  possible  to 
obtain  complete  rest,  active  exertion  should  be  avoided, 
and  the  judgment  and  tact  of  the  attending  physician 
invoked  so  as  to  meet  the  exigencies  of  the  situation. 

In  the  neurasthenic  or  mentally  disturbed  class  of  pel- 
lagrins, complete  rest  is  absolutely  essential,  and  no  marked 
or  lasting  benefit  may  be  expected  without  it. 

In  this  division  of  treatment  may  with  propriety  be  men- 
tioned the  avoidance  of  hght — sunlight  in  particular. 

The  rays  of  the  sun,  especially  in  the  spring  time,  seem  to 
exert  a  peculiarly  irritating  effect  on  the  erythema.  The 
patient  should  be  cautioned  to  keep  out  of  bright  sunlight 
as  much  as  possible,  and,  when  out-of-doors,  to  protect  the 
hands  and  forearms  -with  gloves,  and  the  face  and  neck  with 
a  broad  hat,  veil,  or  umbrella. 

It  has  been  observ^ed  many  times  that  an  impro\dng  ery- 
thema., or  even  a  comparatively  normal  skin  surface,  will 
quickly  flare  up  on  injudicious  exposure  to  the  rays  of  the 
sun. 

The  use  of  the  Rontgen  ray,  either  for  diagnosis  of  any 
condition  or  therapeutically,  should  be  absolutely  inter- 
dicted during  the  course  of  pellagra,  and  for  at  least  one 
year  after  all  s^-mptoms  have  disappeared.  Even  a  brief 
fluoroscopic  examination  is  dangerous. 

The  writer  has  reported  two  cases  (American  Journal  of 
Rontgenology,  November,  19 14)  in  which,  after  exposure 
to  the  rays,  violent  peUagra  promptly  developed.  In 
neither  of  these  patients  was  pellagra  suspected  pre\dous 
to  the  Rontgen  examination. 

As  there  is  good  reason  to  believe  that  latent  or  at}^ic 
pellagra  may  be  fiercely  precipitated  by  the  Rontgen  ray, 
its  employment  should  be  avoided  in  all  suspicious  cases. 


DIFFERENT  METHODS  OF  TREATMENT  199 

The  patient  should  be  enjoined  to  thoroughly  masticate 
the  food,  so  as  to  put  no  undue  burden  on  the  gastro-in- 
testinal  mucosa.  Parenthetically,  in  this  connection, 
might  be  noted  the  advisability  of  putting  the  teeth  in 
order,  A  regular  examination  of  the  oral  cavity  will  re- 
veal many  foul  conditions,  where  tender  or  defective  teeth 
or  pyorrhea  alveolaris  not  only  render  effective  chewing 
impossible,  but  a  constant  supply  of  pathogenic  bacteria 
from  this  cavity  augments  the  auto-intoxication  already 
present. 

The  specific  cause  of  pyorrhea  alveolaris  and  dentalis  has 
apparently  been  placed  upon  endamebas  by  M.  F.  Barrett 
and  Allen  J.  Smith. 

The  writer  recommends  that  in  all  pellagrins  with  the 
slightest  indication  of  buccal  infection,  a  ^-grain  injec- 
tion of  emetin  be  given  every  day  for  six  days.  After  two 
weeks  have  elapsed  this  should  be  repeated;  and,  if  the 
mouth  remains  sore  or  unclean  in  appearance,  the  "six-day 
treatment"  with  emetin  may  be  repeated  four  or  five  times. 

It  is  well,  also,  in  addition  to  any  other  methods  of  treat- 
ing the  sore  mouth,  to  have  the  patient  wash  his  mouth 
twice  daily  with  a  solution  of  3  drops  of  fluidextract  of 
ipecac  in  a  half-glass  of  water.  This  does  not  eliminate 
the  necessity  for  appropriate  dental  attention. 

The  importance  of  obtaining  a  hygienic  state  of  the 
mouth,  the  main  portal  of  entry  to  the  body,  has  been  un- 
derestimated, and  the  medical  attendant  will  find  the  time 
and  trouble  expended  in  putting  this  cavity  in  order  well 
spent. 

Sleeping  in  the  open  air,  as  in  tuberculosis,  has  been 
advocated  by  some,  and  has  its  advantages  when  properly 


200  PELLAGRA 

followed.  An  abundance  of  fresh  air  is  in  order  at  any  stage 
of  the  disease. 

Regular  hours  for  sleep,  for  rest  or  recreation,  or  for  any 
occupation,  no  matter  how  light,  must  be  scrupulously 
kept;  for  the  slightest  form  of  dissipation  will  react  inju- 
riously on  the  sensitive  alimentary  tract  and  unstrung 
nerves. 

As  in  the  dietetic  regimen,  each  individual  case  will 
have  to  be  managed  on  its  merits,  regulating  the  habits  in 
accordance  with  the  financial  ability,  temperamental  status, 
or  var3ang  phases  of  the  illness. 

Hydrotherapeutic  Treatment. — The  effects  of  hydro- 
therapy  in  pellagra  have  in  many  instances  been  so  bene- 
ficial that,  whenever  practicable,  some  forms  should  be 
invoked. 

Hot  or  cold  baths,  simple  and  medicated,  douching, 
packs,  moist  or  dry  rubs,  accompanied  by  special  massage, 
have  proved  their  worth,  bringing  about  increased  oxida- 
tion of  the  tissues,  more  rapid  elimination,  greater  metabolic 
activity,  sharpened  appetite,  improved  digestion  and  assim- 
ilation, and  a  noticeable  tonic  effect  on  the  whole  living 
organism. 

Among  the  indications  for  well-directed  hydrotherapy 
are  vertigo,  stuporous  states,  parasthesias,  tremors,  rigid- 
ity of  the  limbs,  insomnia,  constipation  (occasionally  diar- 
rhea), and  other  neurasthenic  manifestations,  numerous  as 
they  generally  are. 

Either  hot  or  cold  baths  may  be  employed,  the  hot  being 
more  grateful  to  the  extremes  of  life  or  the  feeble.  It 
has  been  ascertained  that  practically  the  same  tissue  changes 
follow  a  hot  bath  as  a  cold  one,  being  caused  by  an  effect  on 


DIFFERENT  METHODS  OF  TREATMENT  soi 

the  innervation  or  the  muscles;  in  fact,  all  combustion 
processes  in  the  body  are  referable  to  the  muscles.  A 
simple  hot-air  bath  may  have  little  effect,  but  a  series  of 
hot-air  or  hot-water  baths  increase  nitrogen  eHmination, 
urea  eUmination  keeping  pace  with  the  excretion  of  nitro- 
gen, and  uric  acid  is  also  excreted  in  greater  quantity. 

"  Elaborate  studies  of  these  metabolic  changes  have 
been  made  by  many  observers,  and  in  connection  with 
ordinary  hydriatic  procedures,  the  half-bath,  the  Scotch 
douches,  etc.  It  is  interesting  to  note  that  Hippocrates 
states  that  the  temperature  elevation  which  occurs  in 
connection  with  most  acute  infectious  diseases  is,  within 
limits,  remedial  in  purpose  and  effect.  It  apparently  fol- 
lows that  temperature  elevation  baths  may  be  beneficial 
in  aiding  resistance  to  infection,  especially  when  followed 
by  a  short  cold  bath,  by  favoring  the  production  of  alexins 
and  antitoxins.  It  seems  to  us,  however,  that  cold  baths 
are  better,  practically,  in  the  infectious  fevers — witness  the 
brilliant  results  attained  by  the  Brand  treatment  of  ty- 
phoid fever.  That  baths  of  such  obviously  different  char- 
acter lead  to  very  nearly  the  same  physiologic  results  is 
one  of  the  seeming  paradoxes  of  hydrotherapy.  This 
is  recognized  in  practice,  for,  if  patients  do  not  react 
well  to  the  cold  baths,  it  is  well  to  give  a  bath  at  iio°  or 

112°  F. 

"  Dr.  Simon  Baruch  explains  this  seeming  paradox  by 
the  physiologic  fact  that  both  heat  and  cold  are  thermic 
irritants,  which,  briefly  applied,  excite  the  peripheral  sen- 
sory terminals  and  thus  stimulate.  The  secondary  effects 
differ  decidedly  if  the  application  be  prolonged  "  (Hins- 
dale) . 


202  PELLAGRA 

A  few  specific  directions  for  some  of  the  baths  will  be 
given,  taken  in  the  main  from  Dr.  Hinsdale's  excellent 
work  on  hydrotherapy. 

The  Warm  Full  Bath. — A  large  tub  is  filled  three-quarters 
full  of  water  at  95°  to  100°  F.,  in  which  the  patient  is  fully 
immersed,  first  having  his  head  covered  with  a  wet  cloth  in 
cold  water.  The  room  should  be  at  a  temperature  of 
about  80°  F.,  and  means  should  be  at  hand  for  maintaining 
the  water  at  its  initial  degree  of  heat,  for  this  bath  is  usually 
prolonged  to  ten,  fifteen,  or  twenty  minutes  or  more,  as 
required.  Indeed,  the  duration  of  a  bath  has  been  extended 
by  Hebra  and  others  to  days  and  even  months,  the  patients, 
some  of  whom  suffered  from  extensive  bums,  bed-sores, 
pemphigus,  and  other  skin  diseases,  existing  in  the  contin- 
uous bath  for  remarkably  long  periods.  If  continued  for 
several  hours,  the  patient  may  sleep  in  the  bath,  but  he 
naturally  requires  constant  attendance,  special  lifting 
apparatus,  and  electric  and  other  appliances  for  maintain- 
ing a  constant  temperature.  For  dermatologic  purposes 
100°  F.  is  considered  best.  Mutton  suet,  lanolin,  or  pe- 
trolatum appKed  thoroughly  to  the  skin  protects  it  from 
puckering  or  peehng. 

Hot  baths  of  greater  or  less  duration,  as  described  above, 
can  exert  a  most  helpful  effect  in  some  of  the  neurasthenic 
pellagrous  patients  where  all  other  methods  have  seemed 
unavailing,  and  the  physician  is  importuned  to  redouble 
his  efforts,  in  the  slender  hope  that  some  good  may  arise. 

The  Cold  Bath. — For  fairly  vigorous  persons  the  best  time 
for  the  cold  bath  is  before  breakfast.  Weak  or  delicate 
persons  may  take  it  in  the  forenoon.  ChiU,  languor,  or 
drowsiaess  comins:  on  after  cold  baths  are  contraindications 


DIFFERENT  METHODS  OF  TREATMENT  203 

to  their  continuance;  tepid  baths  are  then  to  be  substituted. 
Vigorous  friction  should  always  follow  the  use  of  cold. 

The  water  of  a  cold  bath  is  usually  drawn  in  a  tub  from 
the  public  supply,  and  varies,  according  to  the  season,  from 
40°  to  70°  F.  The  cold  bath  is  the  favorite  of  the  Anglo- 
Saxon  race  and  in  those  who  need  to  get  up  a  reaction;  for 
the  drowsy  pellagrins  of  the  "  florid  type  "  or  for  the  robust 
who  tend  to  a  high  temperature  the  plain  cold  bath  is 
often  most  grateful. 

Salt  Bath  or  Rub. — This  may  be  given  as  follows:  The 
patient  is  placed  in  a  tub  of  warm  water,  the  temperature 
of  which  may  be  practically  judged  by  the  hand,  which 
should  be  able  to  bear  it  with  comfort.  The  salt  should 
be  of  a  fine  quaHty  and  should  not  contain  coarse  particles. 
A  good  kitchen  or  cooking  salt  answers  all  requirements. 
The  attendant,  having  stood  the  patient  up  in  the  tub, 
wets  his  hands  and  dips  up  a  handful  of  the  salt.  With  it 
he  thoroughly  and  firmly,  but  not  roughly,  rubs  the  body 
all  over  for  some  fifteen  or  twenty  minutes.  The  patient 
is  then  made  to  lie  down  in  the  water,  the  salt  is  washed  off, 
and  after  a  few  minutes  a  cold  douche  is  given.  He  is  then 
put  to  bed  at  rest  for  a  time.  This  may  be  done  three  or 
more  times  weekly. 

Where  a  powerful  effect  on  the  nervous  system  is  desired 
the  Scotch  douche,  which  is  an  alternating  douche  of  hot 
and  cold  water  or  steam  and  cold  water,  may  be  used. 
The  facilities  for  these  special  forms  of  hydrotherapy  are 
found  only  in  properly  fitted  institutions,  and  their  appli- 
cation should  be  entrusted  only  to  those  who  are  trained 
to  scientifically  use  them,  or  harm  might  result. 

The  use  of  rectal  douches  for  proctitis,  tenesmus,  or  over- 


204  PELLAGRA 

loaded  rectum,  or  irrigation  with  the  recurrent  rectal  tube 
(Kemp's)  for  sedative  or  cleansing  purposes,  have  their 
useful  place,  and  do  not  vary  materially  in  their  indica- 
tions or  application  in  similar  bowel  inflammations  from 
other  causes  than  pellagra. 

The  same  may  be  said  of  vaginal  douches. 

At  all  times  the  patient  should  be  urged  to  drink  a  suflS- 
ciency  of  water,  so  that  the  blood-pressure  may  be  main- 
tained, the  fecal  current  well  supplied  with  moisture,  the 
kidneys  freely  flushed,  and,  by  the  solvent  power  of  the 
water,  the  eliminative  functions  be  enabled  to  dispose  of 
a  maximum  of  toxins. 

The  question  of  gastric  lavage  in  pellagra  is  a  somewhat 
complicated  one.  As  a  routine  measure  it  holds  no  place. 
The  gastric  disturbance  is  not  primary  with  the  stomach 
any  more  than  it  is  with  the  skin,  and  to  attempt  to  con- 
trol the  digestive  manifestations  by  lavage  would  neces- 
sarily prove  disappointing. 

Where  catarrhal  gastritis  complicates  the  trouble,  or  a 
deficient  motor  function  of  the  stomach  or  a  stenosis  of  the 
pylorus  permits  an  undue  damming  of  the  stomach-contents, 
lavage  at  not  too  frequent  intervals  will  afford  some  relief. 

When  this  procedure  is  employed,  it  is  well  to  use  first 
plain  warm  water,  then  the  medicated  fluid,  then  follow 
up  with  plain  water. 

Should  the  lavage  be  followed  by  colicky  pains  or  should 
the  tube  irritate  the  fauces,  it  is  wiser  to  either  discontinue 
it  or  use  it  at  infrequent  intervals. 

Medicinal  Treatment. — The  application  of  medicinal 
remedies  in  pellagra  is,  in  the  opinion  of  the  writer,  fruit- 
ful of  much  benefit.     Many  of  the  most  distressing  symp- 


DIFFERENT  METHODS  OF  TREATMENT  205 

toms  can  be  either  relieved  or  mitigated,  and  just  because 
a  positive  specific  has  not  been  found  is  no  reason  why  a 
therapeutic  pessimism  should  be  allowed  to  dampen  the 
ardor  of  the  physician.  Therapeutic  pessimism  is  the 
inevitable  refuge  of  the  weakling,  and  if  the  medical  at- 
tendant is  imbued  with  that  spirit  he  should  hesitate  in 
treating  pellagra. 

For  the  sore  mouth  and  tongue  an  application  of  nitrate 
of  silver  (20  grains  to  the  ounce  of  water)  daily  or  on  al- 
ternate days  is  recommended.  A  mouth-wash  of  boro- 
glycerin  (25  per  cent.),  or  half-strength  liquor  alkalinus 
antisepticus,  or  a  combination  of  chlorate  of  potash  and 
glycerin,  with  rose-water  as  a  vehicle,  will  generally  prove 
satisfactory.  For  the  aphthous  ulcers,  ofttimes  so  pain- 
ful, gentle  "  touching  "  with  half-strength  aromatic  sul- 
phuric acid  once  daily,  or  a  liberal  application  of  a  mild 
solution  of  salicylic  acid  in  glycerin  and  alcohol,  will  be 
sufl&cient. 

The  emetin  treatment,  as  previously  described,  will  in 
many  instances  promptly  abate  the  sore  mouth. 

For  the  salivation  give  aio-  grain  atropin  every  four 
hours  till  the  dribbling  ceases;  then  stop,  for  the  continu- 
ance of  the  atropin  would  cause  uncomfortable  drjmess  of 
the  mouth  and  fauces. 

Should  the  interior  of  the  buccal  cavity  and  fauces  be- 
come dry  and  uncomfortable,  a  frequent  spra3dng  with 
liquid  albolene,  to  which  a  little  menthol  has  been  added, 
will  prove  most  grateful. 

As  a  constitutional  treatment  the  writer  recommends  the 
following,  which  has  been  evolved  from  his  own  experience, 
augmented  by  suggestions  from  others  in  whom  he  has 
confidence. 


2o6  PELLAGRA 

At  present  the  writer  employs  for  h3^odermic  use  i6- 
minim  ampoules  of  iron  arsenite  solution,  and  ampoules 
of  sodium  cacodylate,  i  c.c,  each  ampoule  containing  f 
grain  of  the  drug.  One  of  each  is  injected  on  alternate 
days,  injecting  them  under  careful  aseptic  precautions. 
This  injection  on  each  day,  but  alternating  the  drug,  is 
kept  up  for  two  or  three  weeks,  then  the  injection  is  given 
every  second  day,  still  alternating  the  ampoules,  for  two 
or  three  weeks  longer.  After  that  the  injections  are  given 
only  about  once  a  week  (still  alternating),  as  long  as  it  is 
practicable  or  considered  advisable. 

Internally  it  is  recommended  that  a  combination  of  Fow- 
ler's solution  and  a  saturated  solution  of  potassium  iodid 
be  given,  beginning  in  s-drop  doses  and  increasing  i  drop 
daily  until  the  physiologic  limit  is  reached.  Generally 
the  puffiness  under  the  eyes  appears  when  about  25  to  30 
drops  are  being  taken.  When  this  appears,  the  drops  should 
be  discontinued  for  two  days,  and  started  at  the  minimal 
dose  of  5  drops,  increasing  gradually  as  before.  Some  can 
take  larger  doses  without  discomfort  than  others,  but  it 
answers  no  good  purpose  to  push  it  after  the  physiologic 
limit  has  been  reached.  Occasionally  the  patient,  on  ac- 
count of  excessive  irritability  of  the  alimentary  tract,  will 
prove  intolerant  of  arsenic  internally.  Should  this  be 
apparent,  the  saturated  solution  of  potassium  iodid  alone 
may  be  pushed,  given  in  a  Kttle  sweet  milk. 

This  is  the  formula: 

I^.    Liquor  potassii  arsenitis 3  drams. 

Saturated  solution  kalium  iodid 5      " 

The  number  of  patients  who  could  not  tolerate  this 
formula  have  been  extremely  few. 


DIFFERENT  METHODS  OF  TREATMENT  207 

After  the  active  symptoms  of  pellagra  have  abated,  and 
iron  does  not  seem  to  be  indicated,  this  formula  may  be  kept 
up  almost  indefinitely  in  6-  or  8-drop  doses  three  times 
daily. 

For  the  frequent  diarrhea,  bismuth-betanaphtol  and 
resorcin,  given  with  milk  of  bismuth  as  a  vehicle,  has 
generally  been  sufficient.  This  failing,  there  may  be  given 
tannigen,  protan,  or  heavy  doses  of  bismuth  subgallate. 
As  a  last  resort,  powdered  opium  or  tincture  of  opium  may 
be  used,  but  opium,  as  an  intestinal  astringent  in  pellagra, 
has  its  disadvantages,  as  it  seriously  interferes  with  the 
much-needed  elimination.  The  writer  prefers  lo-grain 
doses  of  tannigen,  given  as  indicated  by  the  severity  of  the 
diarrhea. 

When  there  is  a  paucity  or  absence  of  free  hydrochloric 
acid  in  the  gastric  secretions,  10  or  12  drops  (not  more) 
of  dilute  hydrochloric  acid,  well  diluted  and  given  thirty 
minutes  after  meals,  will  often  greatly  aid  digestion  and 
lessen  the  "  heavy  feeling  "  so  much  complained  of. 

For  the  anorexia,  tincture  of  nux  vomica,  condurango, 
calumba  or  quassia,  with  compound  tincture  of  gentian  or 
cinchona  as  a  vehicle,  will  often  sharpen  an  indifferent 
appetite  if  given  a  short  time  before  meal  time. 

In  anemic  or  cachectic  conditions  the  various  ferrugin- 
ous preparations  are  indicated,  as  well  as  cod-liver  oil, 
oHve  oil,  or  official  preparations  of  the  hypophosphites. 

A  malarial  complication,  often  present,  either  openly  or 
latently,  will  require  the  addition  of  quinin,  which  may  be 
administered  in  the  most  eligible  form. 

Constipation,  when  present,  may  be  controlled  by  castor 
oil  or  enemas,  drastic  cathartics  being  inadmissible.     In 


2o8  PELLAGRA 

these  infrequent  cases  of  constipation  in  pellagra  an  in- 
jection of  2  to  4  ounces  of  cotton-seed  or  oUve  oil,  intro- 
duced into  the  rectum  on  retiring  and  kept  in  all  night, 
will  generally  produce  a  soft,  unirritating  and  effectual 
evacuation  of  the  bowels  the  next  morning. 

The  writer  is  also  employing,  with  good  results,  the  Hquid 
paraffin,  given  as  required — generally  a  tablespoonful  night 
and  morning. 

Mention  might  also  be  made  of  phenolphthalein,  which,  in 
I-  or  2-grain  doses  at  night,  is  followed  by  satisfactory 
movements. 

At  present,  reports  of  the  use  of  hexamethylenamin  are 
being  sent  in  with  some  frequency,  and  it  may  be  found  that 
in  this  preparation  a  useful  agent  has  been  found.  Its 
physiologic  elimination  in  the  urine,  bile,  cerebrospinal 
fluid,  and  other  fluids  of  the  body  may  enable  this  drug  to 
exercise  an  antitoxic  effect. 

Ichthyol,  too,  is  recormnended  by  some. 

The  symptoms  of  nervous  irritation,  expressed  by  burn- 
ing hands,  feet,  or  mouth,  will  often  tax  to  the  uttermost  the 
resources  of  the  physician.  These  may  be  combated  by 
compresses  saturated  with  a  mild  solution  of  bichlorid  of 
mercury,  ice  cold,  and  applied  at  frequent  intervals;  by 
baths  in  hot  mustard  water  or  very  sHghtly  mentholated 
applications  of  Hquid  albolene.  In  occasional  instances 
this  burning  becomes  so  intolerable  as  to  require  an  ano- 
dyne. 

The  aches  and  shooting  pains  may  often  be  aUeviated  by 
5 -grain  doses  of  acetylsalicylic  acid,  given  four  times  daily. 
This  sometimes  burns  the  stomach,  but  not  often.  Phe- 
nacetin,  to  which  is  added  a  small  amount  of  citrate  of 


DIFFERENT  METHODS  OF  TREATMENT  209 

cafifein,  may  also  be  employed  for  the  headache  or  the 
different  neuralgias. 

Massage  in  some  instances  affords  decided  relief  in  mus- 
cular pains,  and  the  rubbing  in  of  a  gently  stimulating  lin- 
iment is  not  amiss. 

The  erythema,  being  a  secondary  symptom,  should  re- 
ceive only  palliative  treatment.  Too  many  applications 
tend  to  irritate  more  than  soothe,  and  too  many  ointments 
can  sometimes  transform  a  dry  erythema  into  a  moist  one, 
which  is  far  from  being  desirable. 

While  the  hands  are  red  and  hot,  a  lotion,  as  suggested 
by  Dr.  Babcock,  is  serviceable: 

Pulv.  calamine 4  drams. 

Pulv.  zinc  oxid 3      " 

Rose-water 2  ounces. 

Lime-water,  to  make i  pint. 

This  may  be  applied  ad  libitum. 

After  desquamation  begins,  there  aire  several  mild  oint- 
ments available. 

The  writer  has  used  with  satisfaction  the  5  per  cent, 
boric  acid  ointment.     Dr.  Babcock  recommends: 

Pulv.  calamine I  dram. 

Zinc  oxid \ 

Olive  oil I      " 

Lanolin,  to  make i  ounce. 

Gentle  cleansing  of  the  scales  or  crusts,  after  having 
been  softened  with  some  oily  substance,  will  promote  the 
comfort  of  the  patient. 

When  other  applications  to  sore  and  crusted  skin  have 
failed,  the  writer  recommends  the  scarlet-red  ointment 
(Heilkraft),  This  may  be  applied  once  or  twice  daily  and 
is  quite  efficacious.  An  objection  to  its  use  is  the  stain  it 
produces  upon  any  article  it  touches. 

14 


2IO  PELLAGRA 

When  the  erythema  attacks  the  eyelids  and  sympathetic 
conjunctivitis  ensues,  a  weak  solution  of  aigyrol  dropped 
in  the  eyes  will  generally  prove  adequate  for  relief. 

For  great  exhaustion,  the  intravenous  injection  of  saHne 
solution  (300  c.c),  every  day  or  alternate  day,  is  suggested. 

For  the  mental  and  psychic  symptoms,  appearing  as 
they  do  in  such  multitudinous  forms,  only  general  sugges- 
tions can  be  made.  To  treat  these  manifestations  by  any 
rule-of-thumb  would  be  irrational  and  fruitless. 

Sleeplessness  may  be  combated  by  chloral,  trional,  or 
veronal.  By  the  addition  of  phenacetin  to  veronal  the 
good  effect  is  augmented  and  disagreeable  after-effects 
prevented.  Morphin  or  codein  for  insomnia  is  to  be  dep- 
recated. 

Tincture  of  opium  or  powdered  opium  are  useful  for  the 
melancholia,  but  they  must  be  aided  by  isolation  and  rest. 

Dr.  Hansell  Crenshaw  beheves  that  the  degenerative 
changes  in  the  cord  and  brain  are  best  resisted  by  iodids, 
mercurials,  and  arsenic.  In  short,  he  believes  that  the  rav- 
ages of  pellagra  upon  the  nervous  tissues  are  similar  to  the 
ravages  of  syphihs  upon  these  tissues,  and  that  the  treat- 
ment should  be  parallel.  His  explanation  of  the  apparent 
failure  of  salvarsan  to  aid  pellagra  is  based  on  the  hypoth- 
esis that  the  drug  has  not  been  adjusted  to  pellagra  by 
606  careful  experiments,  as  it  has  in  s^-phihs. 

When  the  mental  symptoms  deepen  into  the  more  pro- 
nounced forms  of  melancholia  or  lapse  into  dementia  or 
amentia,  the  patient  should  be  put  in  an  institution  for 
the  mentally  sick.  These  unfortunate  invahds  are  subject 
to  so  many  varying  moods,  suicidal  and  otherwise,  that  it 
is  almost  impracticable  to  properly  and  safely  care  for  them 
at  home. 


DIFFERENT  METHODS  OF  TREATMENT  211 

While  many  of  the  pellagrous  neuroses  and  psychoses 
are  the  result  of  degenerative  changes,  where  scar  tissue 
impedes  and  cuts  off  conduction,  still,  in  many  instances, 
if  the  treatment  is  persisted  in  with  a  spirit  of  optimism, 
unexpected  improvement  may  brighten  a  gloomy  prognosis 
and  light  may  emerge  from  sad  obscurity. 

We  are  not  as  yet  thoroughly  conversant  with  the  influ- 
ences of  the  mind  over  metabolic  processes  upward  or  down- 
ward, and,  while  due  caution  should  always  be  observed  in 
any  predictions,  no  one  man  nor  set  of  men  are  privileged  to 
abrogate  the  functions  of  a  supreme  court  by  asserting  that 
pellagra  is  an  incurable  disease,  and  that  medical  treatment 
is  valueless. 

Climatic. — Pellagra,  being  in  the  main  a  disease  of  hot 
weather,  it  has  been  found  in  nearly  every  instance  that  a 
sojourn  to  a  cooler  climate  was  beneficial.  Cold  climates, 
or  those  where  the  winters  are  long  and  the  summers  corres- 
pondingly short,  have  never  seemed  to  furnish  a  congenial 
soil  for  the  spread  of  pellagra. 

Goldberger  beHeves  that  a  change  in  climate  is  valuable 
only  in  proportion  to  the  degree  and  character  of  the  change 
of  diet  it  involves.  With  this  assumption  the  writer  does 
not  agree. 

Pellagrins,  unless  too  far  advanced,  get  better  with  cold 
weather,  and  only  the  practically  hopeless  cases  go  on  to 
exhaustion  and  death  in  the  winter  season. 

Many,  from  financial  or  other  reasons,  cannot  seek  a  cool 
climate,  but  all  that  can  should  avail  themselves  of  this  aid. 
In  this  country,  in  order  to  reach  a  cool  climate  in  the 
summer  time,  a  high  altitude  must  be  sought,  and  careful 
advice  must  be  given  regarding  the  influence  of  altitude 
on  the  vital  organs. 


212  PELLAGRA 

It  has  been  the  experience  of  the  writer  and  others  that 
the  benefit  to  the  pellagrous  symptoms  nearly  always  ex- 
ceeds the  possible  danger  of  high  altitude,  and,  unless  there 
are  strong  reasons,  this  consideration  should  not  prevent 
cHmatic  change. 

In  order  to  reap  the  full  benefits  from  this  change  the 
writer  believes  that  the  pellagrin  should  avoid  hot  weather 
for  ten  or  twelve  months  after  all  symptoms  have  disap- 
peared. 

Where  it  is  not  practicable  to  reach  an  actually  cool 
climate,  a  lesser  change  is  sometimes  beneficial,  but  the 
change  should  always  be  to  a  higher  latitude  and  altitude 
— never  a  lower  one. 

This,  in  both  a  general  and  specific  maimer,  covers  the 
treatment  of  pellagra.  Much  of  it  has,  of  necessity,  been 
rather  general,  but  the  writer  feels  that  the  therapeutic 
field,  according  to  the  present  knowledge  of  the  disease, 
has  been  fairly  covered. 

Our  pellagrous  charges  expect  an  honest  effort  to  be  ex- 
pended in  their  behalf;  they  demand  it,  and  we,  as  healers 
of  the  sick,  have  no  right  to  consign  them  to  the  "slough 
of  despond,"  nor  have  we  the  moral  claim  to  banish  this 
disease  to  the  limbo  of  "incurable  affections." 

Let  us,  therefore,  give  our  suffering  and  disconsolate 
pellagrins  the  full  benefit  of  our  knowledge  as  we  acquire 
it,  hoping  in  the  meanwhile  that  the  discovery  of  a  specific 
treatment  may  be  attained  in  the  near  future. 


CHAPTER  IX 
THE  PROPHYLAXIS  OF  PELLAGRA 

This  important  chapter  in  the  discussion  of  pellagra  un- 
fortunately must  be  approached  from  a  theoretic  standpoint, 
for,  until  we  have  positive  information  as  to  etiology,  we 
are  necessarily  dealing  in  assumptions,  not  in  proved  facts. 

One  of  the  first  questions  that  arises  is  concerning  the 
communicability  of  pellagra,  for  on  that  hinges  much  of  the 
prophylaxis. 

The  consensus  of  opinion  at  present  is  against  the  possi- 
bility of  this  disease  being  either  contagious  or  infectious, 
but  toxicochemical,  and,  as  such,  it  cannot  be  transmitted 
from  one  individual  to  another. 

As  early  as  the  middle  of  the  last  century  Roussel 
wrote:  "  It  can  be  said  of  the  contagion  of  pellagra  that  it 
is  a  question  fully  determined — pellagra  is  not  contagious." 

To  admit  this,  or  to  attribute  the  spread  of  pellagra  to 
a  contagion  or  an  infection,  would  bring  up  the  questions  of 
isolation  and  quarantine,  serious  questions  to  individuals 
and  communities,  unless  supported  by  strong  reasons. 

Italy  has  suffered  and  so  have  other  European  countries, 
some  of  whom  have  apparently  solved  the  problem,  but 
it  was  solved  according  to  the  zeist  doctrines. 

Apart  from  the  ordinary  precautions,  hygienic  and  die- 
tetic, already  considered,  the  prophylaxis  will  be  covered  by 
an  account  of  the  methods  of  prevention  in  other  countries, 

213 


214 


PELLAGRA 


that,  from  their  long  and  trying  experiences,  we  may  learn 
and  perhaps  utilize  some  of  their  methods. 

Joseph  n.,  of  Austria,  was  the  first  sovereign  to  concern 
himself  with  pellagra,  giving  those  who  sought  to  prevent 
and  treat  it  all  the  aid  in  his  power. 

The  first  serious  attempt  in  Italy  to  deal  with  the  prob- 
lem was  in  1879,  ten  years  after  Lombroso's  fame  was  es- 
tablished. 

Much  of  the  following  is  extracted  from  the  consular 
report  rendered  by  the  late  Bayard  Cutting,  Jr.,  and  pub- 
hshed  by  the  United  States  Government. 

In  the  year  above  mentioned  a  census  Vv^as  taken  of  the 
pellagrous  patients  in  Italy,  and  as  a  result  of  the  census 
a  bin  was  introduced  for  the  regulation  of  com  cultivation 
and  importation,  and  the  estabhshment  of  desiccating 
machines.  The  bill  failed,  and  the  only  immediate  result 
of  the  census  was  an  annual  grant  of  36,000  lire  from  the 
Government  toward  the  relief  of  pellagra — about  6  cents 
for  each  patient.  This  amount  was  raised  at  a  later  date, 
until  it  amounted  to  70.000  lire  in  1889;  and  under  the  law 
of  1902,  100,000  lire  are  contributed  annually  for  the  pre- 
vention and  cure  of  pellagra,  and  as  much  more  for  the  in- 
troduction of  improved  methods  of  agriculture.  The  census 
of  1879  was  an  epoch-making  event.  It  brought  home  to 
the  people,  as  a  whole,  the  gravity  of  the  situation,  and  it 
stimulated  the  various  provincial  governments  to  act  in- 
dependently. Man}'  provinces  appointed  pellagrologic 
commissions,  took  censuses,  and  founded  hospitals  or 
"  local  sanitariums."  From  1879  to  1903  was  a  period  of 
local  and  provincial  activity.  The  conclusions  of  doctors 
were  tested  on  a  small  scale,  and  the  way  prepared  for  gen- 


THE  PROPHYLAXIS  OF  PELLAGRA        215 

eral  legislation.  Meanwhile,  in  1895,  the  Crispi  adminis- 
tration issued  an  ordinance  forbidding  the  importation  of 
spoiled  corn,  and  providing  for  inspection  at  chief  ports. 
In  1902  the  "  law  for  the  prevention  and  cure  of  pellagra" 
was  passed,  and  in  the  following  year  was  issued  the  regu- 
lations for  the  enforcement  of  the  law.  Since  that  time 
five  years  have  elapsed,  and  already  pellagra  may  be  said 
to  be  a  doomed  disease.  The  statistics,  so  hard  to  inter- 
pret as  regards  particular  details,  bear  unmistakable  testi- 
mony to  a  general  decHne  in  the  disease  under  the  operation 
of  the  law. 

The  main  provisions  of  the  law  and  regulations  are  as 
follows : 

I.  Absolute  prohibition  of  the  importation,  sale,  holding 
for  sale,  or  grinding  of  spoiled  corn  or  products  of  corn 
destined  for  human  food.  If  the  corn  is  destined  to  feed 
animals  or  to  be  used  for  other  purposes,  it  is  admitted 
only  by  special  permit  of  the  prefect. 

II.  Obligation  upon  all  communes  to  report  cases  of 
pellagra.  A  commune  with  several  cases  is  declared  pel- 
lagrous, and  falls  under  the  following  provisions: 

(i)  Government  inspection  of  all  corn  dried,  stored,  and 
consumed  in  the  commune. 

(2)  Obligation  on  the  part  of  commune  and  province  to 
establish  public  desiccating  plants,  to  provide  curative 
nourishment  for  all  patients,  to  provide  patients  and  their 
families  with  free  salt,  and  to  treat  severe  cases  in  special 
institutions. 

III.  Establishment  of  pellagrologic  commissions  in  all 
provinces  affected  with  the  disease. 

IV.  Assignment  of  a  government  grant  of  200,000  lire 


2i6  PELLAGRA 

annually,  and  obligation  upon  the  provinces  and  communes 
to  defray,  in  equal  portions,  the  expenses  entailed  by  the 
act. 

This  is  the  charter  under  which  the  struggle  against 
pellagra  is  now  being  carried  on.  It  is  proposed  to  examine 
the  several  dispositions  of  the  act,  then  to  give  some  details 
in  regard  to  certain  provinces  which  Mr.  Cutting  was  able 
to  investigate  in  person,  and,  finally,  to  append  such  other 
data  as  will  be  of  the  most  profit  to  those  interested  in  the 
fight  being  waged  by  Italy  against  this  scourge. 

It  will  not  be  necessary  or  appropriate  to  enter  into  the 
public  curative  measures,  but  the  well-ordered  prophylactic 
measures  will  be  described.  Those  chiefly  to  be  noted  are: 
The  testing  of  com  and  flour  brought  in  at  the  frontier, 
or  offered  for  sale  or  brought  to  the  mill,  the  exchange  of 
bad  com  for  good,  desiccating  plants,  cheap  co-operative 
kitchens,  the  improvement  of  agricultural  methods,  and 
the  instruction  of  the  people  as  to  the  danger  of  bad  com. 

The  first  preventive  measures  are  to  protect  the  peasant 
from  imported  spoiled  corn.  He  must  be  taught  to  grow 
com  that  will  ripen,  to  harvest  it  ripe,  to  dry  and  store  it 
properly,  and  to  see  that  it  does  not  become  spoiled  in 
milling. 

Such  cautions  do  not  apply  to  Italy  alone,  but  might  be 
suitably  inaugurated  in  the  United  States. 

Prohibition  of  Spoiled  Com. — As  far  as  regards  corn  im- 
ported from  abroad,  the  provisions  of  the  law  of  1902  seem 
adequate  in  most  respects.  All  suspicious  cargoes  are 
tested  by  experts,  and,  if  the  condition  is  not  satisfactory, 
the  corn  must  be  sent  to  a  distillery  or  else  be  denatured. 
Spoiled  com  can  be  detected  in  a  number  of  ways.     Such 


THE  PROPHYLAXIS  OF  PELLAGRA         217 

outward  signs  as  mildew  or  the  smell  of  mold  are,  of  course, 
conclusive,  but  they  can  be  removed  by  drying  in  the  sun; 
their  absence,  therefore,  does  not  prove  the  soundness  of 
the  corn.  But  the  consumer  should  be  warned  against  any 
corn  that  is  covered  with  dust,  that  is  damp  to  the  touch, 
or  that  gives  forth  any  smell  of  mold  when  warmed  in  the 
palm  of  the  hand.  He  should  be  on  his  guard  against  corn 
of  a  pale  color  with  a  dull  surface. 

There  are  several  chemical  tests  for  distinguishing  sound 
from  moldy  corn.  The  first  test  is  the  proportion  of 
ashes.  It  is  said  that  no  sound  corn  contains  more  than 
4  per  cent,  of  ashes.  This  point  is  doubtful,  and  the  test 
requires  an  accurate  apparatus,  and  is  unsuitable  for  gen- 
eral use  in  inspecting  imported  corn.  The  second  test 
is  that  of  Gosio,  with  perchlorid  of  iron.  Corn-flour  which 
has  been  kept  in  double  its  volume  of  alcohol  (at  80  degrees) 
for  several  days,  being  frequently  shaken  meanwhile,  and 
exposed  to  the  sun  or  to  heat,  is  tested,  after  the  alcohol  has 
been  filtered  and  evaporated  away,  in  a  bath  of  perchlorid 
of  iron  solution.  The  reaction  varies  in  color,  from  a 
dark  green  to  a  violet  blue,  according  to  the  soundness  of 
the  corn.  This  test,  though  one  of  the  best,  is  not  entirely 
sufficient.  It  should  be  supplemented  by  the  test  of  acid- 
ity, since  moldy  corn  is  always  more  acid  than  sound. 

The  biologic  test  of  fruitfulness  is  one  of  the  best,  since 
spoiled  corn  is  certain  to  lose  much  of  its  germinating  qual- 
ity. The  test  is  easy  to  apply,  but  is,  of  course,  ineffective 
for  corn  which  has  been  desiccated.  There  is  also  the  test 
of  poisonous  content  by  the  actual  inoculation  of  mice. 

In  theory,  possibly  all  of  these  tests  are  required,  but 
for  practical  purposes  it  may  be  said  that  corn  which  ap- 


2i8  PELLAGRA 

pears  perfectly  sound,  and  which  does  not  react  to  the. 
perchlorid  test,  is  pretty  sure  to  be  harmless.  In  doubtful 
cases  the  germination  and  acidity  test  can  be  employed. 

Inspection  of  corn  at  the  frontiers  is  comparatively  easy, 
but  at  the  mills  or  in  the  markets,  and  especially  in  the 
shape  of  flour,  it  is  practically  impossible.  The  flour 
problem  is  entirely  beyond  the  control  of  any  govermnent; 
the  only  hope  of  its  solution  would  lie  in  government  or 
municipal  ownership  of  all  mills.  This  proposal  is  eagerly 
supported  by  those  interested  in  the  pellagra  question;  it 
is  certainly  more  practical  than  any  plan  for  diminishing 
the  com  area  in  Italy  or  for  prohibiting  entirely  the  im- 
portation of  com.  Whether  it  is  likely  to  be  adopted  is  as 
yet  uncertain.  Meanwhile,  and  so  long  as  milling  is  a 
private  industry,  the  effort  must  be  made  to  send  only  sound 
com  to  the  mill. 

Every  province  of  Italy  has  a  commission  for  the  en- 
couragement of  improved  methods  of  agriculture.  These 
"  moving  chairs  " — or,  as  we  might  call  them,  farmers'  in- 
stitutes— are  active  institutions  which  have  contributed 
notably  to  Italy's  great  agricultural  progress  during  the 
last  decade. 

These  farmers'  institutions  are  now  in  successful  opera- 
tion in  many  states  in  our  country,  augmented  in  some  in- 
stances by  trains,  educational  in  their  scope,  which  go  from 
place  to  place  teaching  the  doctrine  of  scientific  farming. 
"  Corn  shows  "  also  are  being  held,  where  the  principles 
of  raising  more  and  better  grain  are  inculcated  to  the  masses 
in  an  attractive  manner. 

In  solving  the  pellagra  problem  they  co-operate  very 
usefully    with    the    provincial    pellagrologic    commission. 


THE  PROPHYLAXIS  OF  PELLAGRA        219 

The  pellagrologist  wishes  to  get  rid  of  the  quarantino  corn ; 
the  cattedre  amhulanti  show  the  farmer  a  better  crop  than 
quarantino,  teach  him  how  to  grow  it,  and  prove  to  him  by- 
actual  experiments  that  the  new  crop  is  more  profitable  than 
the  old.  The  rapid  disappearance  of  quarantino  in  Lom- 
bardy  and  Venetia  is  largely  the  result  of  intelligent  mission- 
ary work  by  these  agricultural  commissions.  Instead  of 
quarantino  the  peasant  is  taught  to  plant  the  mathilde, 
millet,  mustard,  or  some  kind  of  forage.  There  is  no  doubt 
that  all  of  these  crops  are  more  profitable,  as  a  second  crop, 
than  quarantino. 

It  is  no  small  triumph  to  have  convinced  the  ItaHan 
peasant  of  the  fact,  and  to  have  induced  him  to  abandon  a 
traditional  crop  for  one  with  which  he  was  not  famihar. 
Next  to  the  inspection  of  foreign  corn,  the  diminution  in 
the  supply  of  quarantino  has  probably  accounted  more 
than  any  other  factor  for  the  encouraging  decrease  of 
pellagra  during  the  last  five  years. 

Desiccating  Plants. — Artificial  drying  of  Indian  com 
was  practically  unknown  in  Italy  until  within  a  few  years. 
Such  corn  as  was  dried  at  all  was  merely  hung  in  the  open 
air,  on  frames,  at  the  sides  of  the  houses.  Most  of  the  corn 
was  stored  as  soon  as  gathered  and  in  any  storing  place 
that  was  available,  without  regard  to  ventilation  or  clean- 
liness. If  Italy  is  the  home  of  pellagra,  while  Mexico  and 
Burgundy  are  entirely  free  from  the  scourge,  the  difference 
may  be  due  simply  to  the  fact  that  in  Mexico  and  Burgundy 
corn  is  fired  almost  as  soon  as  harvested.  Artificial  desic- 
cation is  the  most  important  of  all  prophylactic  measures 
against  pellagra.  It  has  objections,  however,  to  encounter 
from  the  farmers.     The  corn  loses  weight,  they  say.     This 


220  PELLAGRA 

is  true,  but  the  weight  lost  from  decay  is  far  greater.  It 
will  not  germinate.  This  is  true  likewise  if  the  desicca- 
tion is  not  properly  performed;  but  the  best  desiccators 
leave  the  com  with  all  its  natural  properties  unimpaired. 
It  is  expensive.  Not  so  expensive,  on  the  whole,  as  the 
out-door  frames.  The  best  desiccator  yet  contrived,  that 
of  Pietro  Cattaneo,  dries  no  pounds  of  com  w^th  a  fuel 
consumption  of  one  cent.  Nevertheless,  in  order  to  re- 
move as  far  as  possible  the  objection  of  expense,  the  law 
of  1902  provides  that  every  family  may  dry,  at  the  pubhc 
desiccator  free  of  charge,  so  much  corn  as  is  required  for 
the  household  needs.  Further  use  of  the  desiccator  must 
be  paid  for,  but  at  rates  which  allow  nothing  for  profit. 

Desiccators  are  of  two  t}'pes — fixed  and  portable.  The 
portable  type  has  the  great  advantage  of  saving  the  cost 
of  transportation  of  the  com.  It  can  be  carried  in  sec- 
tions and  set  up  in  the  middle  of  a  com  belt.  It  is  cheap 
enough  to  be  within  the  means  of  the  poorer  classes.  The 
fixed  type,  however,  is  infinitely  preferable.  The  air  is 
kept  at  an  even  temperature  and  circulates  equally  in  all 
parts  of  the  machine;  thus  none  of  the  com  is  spoiled  or 
deprived  of  any  of  its  properties.  Air  heated  by  a  furnace 
is  forced  into  a  chamber  of  seven  stories.  Each  stor}'  is  a 
revolving  wire  tray,  containing  about  1400  pounds  of  com. 
The  top  tray  is  filled  from  above.  After  a  certain  time  its 
contents  are  emptied  by  pressing  a  lever  into  the  tray  below 
in  such  a  way  that  they  are  thoroughly  remixed.  The  com 
thus  passes  gradually  to  the  bottom  tray,  whence  it  goes  to 
a  receptacle  where  it  is  cooled  b}'  means  of  a  ventilator, 
and  thence  out  of  the  machine  by  an  inclined  plane.  The 
first  tray-load  of  corn  takes  seven  hours  to  pass  through  the 


THE  PROPHYLAXIS  OF  PELLAGRA         221 

machine;  after  that  1400  pounds  come  out  each  hour. 
The  cost  of  the  machine  is  about  $540,  and  the  power  re- 
quired to  run  it  about  2^  horse-power.  Larger  machines 
of  the  same  kind,  costing  about  $1840,  have  a  daily  capacity 
of  88,000  pounds,  and  require  an  engine  of  8  horse-power. 
In  the  Cattaneo  desiccator  the  air  is  forced  through  the 
trays  in  both  an  upward  and  downward  direction;  the  air 
which  has  absorbed  dampness  from  the  corn  is  replaced 
constantly  by  dry  air;  the  temperature  is  kept  low  (about 
104°  F.),  with  economy  of  fuel  and  without  risk  of  injuring 
the  corn;  and  the  mechanism  is  so  simple  that  the  machine 
can  be  handled  by  any  laborer  of  ordinary  intelligence. 

The  best  of  the  movable  desiccators  is  probably  the  Boltri, 
which  costs  about  $112,  but,  on  account  of  the  danger  of 
destroying  the  germinating  power  of  the  com,  it  is  best 
always,  if  possible,  to  employ  the  more  expensive  machines. 

Desiccation,  if  applied  to  moldy  com,  will  remove  the 
moldy  appearance,  but  in  order  to  kill  the  poison  germ  a 
temperature  not  merely  uneconomical,  but  actually  de- 
structive of  the  grain,  would  be  required.  It  is,  therefore, 
of  the  utmost  importance  to  prevent  the  use  of  the  public 
desiccator  for  com  which  is  even  a  little  spoiled. 

Public  Storehouses. — Another  article  in  the  law  of  1902 
gives  power  to  prefects  to  order  the  authorities  of  any  pel- 
lagrous communes  to  found  a  municipal  storehouse  for  the 
use  of  such  inhabitants  as  do  not  possess  sanitary  houses; 
yet  the  insanitary  conditions  under  which  com  is  stored  in 
the  houses  of  peasants  have  long  been  recognized  as  a 
potent  producer  of  pellagra. 

Ceresoli  recently  said:  "  The  greatest  injury  to  this  food 
is  inflicted  by  those  who  are  to  use  it.     The  com  is  kept  al- 


222  PELLAGRA 

most  always  in  the  darkest  comers  of  the  rooms,  against 
damp  walls,  surrounded  by  dirty  clothes,  exposed  to  all 
human  emanations,  and  to  all  those  foreign  substances 
introduced  by  animals  and  insects.  .  .  .  Pellagra  will  not 
cease  until  the  worst  houses  are  destroyed,  the  rust  cleaned, 
and  the  corn  stored  in  a  place  apart." 

There  is  no  doubt  that  the  public  storehouses  will  come, 
but  for  the  present  the  cost  of  construction  and  mainte- 
nance and  the  expense  of  transportation  are  beyond  the 
means  of  the  ItaHan  communes. 

Rural  Bakeries. — -The  effort  to  eliminate  from  the  diet  of 
peasants  bread  made  of  Indian  com  and  to  substitute 
wheaten  bread  has  taken  shape  in  the  establishment  of 
bakeries,  where  good  wheaten  bread  is  furnished  at  cost. 
The  institution  is  comparatively  new.  In  1904  there  were 
only  77  such  bakeries,  and  in  1905,  89;  but  in  1906  the 
number  had  risen  to  584,  and  in  1907,  to  591.  There  is 
no  question  that  corn-bread  wiU  soon  cease  to  be  a  common 
article  of  food  in  northern  Italy,  and  the  elimination  of 
corn-bread  will  mean,  if  nothing  else,  added  variety  in  the 
diet  of  agricultural  classes. 

Com  Exchanges. — The  idea  of  an  exchange  where  moldy 
com  could  be  exchanged  for  good  is  due  to  Prof.  CeresoH, 
who  carried  it  into  execution  at  Bagnolo  Mella.  The  peas- 
ants bring  their  com,  good  or  bad,  and  receive  in  exchange 
a  lesser  amount  of  perfect  flour,  deduction  being  made  for 
the  cost  of  milling  and  for  any  defects  in  the  com  delivered. 
The  cost  of  the  operation,  which  was  met  at  jMagnolo  Mella 
by  charitable  gifts,  amounted  to  23  cents  per  hundred 
pounds  of  com.  At  this  place  the  exchange  was  popular 
with  the  community;  it  meets  with  the  approval  of  all  stu- 


THE  PROPHYLAXIS  OF  PELLAGRA         223 

dents  of  pellagra,  and  it  is  not  very  expensive  in  the  com- 
parison with  the  immense  benefit  conferred.  Neverthe- 
less, the  scheme  has  not  been  successful.  In  1904  there  were 
four  exchanges,  and  439  quintals  of  corn  exchanged;  in  1905 
the  figures  rose  to  seven  and  1145,  only  to  fall  in  1906  to 
five  and  674,  and  in  1907  to  four  and  292,  for  the  exchange 
will  never  give  more  than  five  kegs  at  a  time,  and  usually 
gives  only  one  keg,  in  order  that  the  flour  may  not  have  time 
to  spoil  at  home. 

The  following  may  be  considered  the  general  conclusions 
of  those  who  have  made  this  fight  as  to  the  lessons  learned 
and  the  results  obtained.  The  list  of  preventive  measures 
against  pellagra  is  by  no  means  exhausted,  and  many  have 
been  suggested  which  have  not  been  adopted.  In  general, 
the  object  is  to  get  at  the  children;  to  prevent  pellagrous 
mothers  from  nursing  their  babies,  or,  if  this  cannot  be 
prevented,  to  see  that  the  mothers  are  well  fed;  to  treat  a 
child  the  moment  he  or  she  shows  the  slightest  symptoms  of 
pellagra,  and  to  send  the  little  patient  away  from  the  sur- 
roundings where  the  pellagra  has  been  acquired.  There 
are  authorities,  however,  and  of  the  highest  rank,  who  see 
no  remedy  for  pellagra  short  of  the  total  elimination  of  com 
as  human  food.  Some  would  forbid  its  importation;  others, 
who  have  noticed  that  pellagra  increases  when  corn  is  dear, 
would  throw  open  the  ports  of  the  country  by  the  removal 
of  the  protective  duty.  Still  others  wish  for  the  prohibition 
of  the  cultivation  of  certain  kinds  of  corn,  or  of  all  corn  in 
locaHties  where  it  is  not  "  economically  profitable."  So 
long  as  national  habits  remain  what  they  are,  so  long  will 
there  be  a  demand  for  a  certain  amount  of  corn.  If  im- 
portation is  difficult,   the  home  crop  will  increase,   and 


224  PELLAGRA 

vice  versa.  It  is  not  by  legislative  restrictions,  but  through 
changes  in  a  national  taste,  that  corn  consumption  can  be 
diminished.  Education  of  the  people  to  the  dangers  of 
bad  corn,  their  awakening  to  the  possibiHty  and  pleasantness 
of  a  varied  diet — there  is  the  remedy.  Much  is  being  done 
to  educate  the  people.  The  industrious  Permanent  Com- 
mittee of  the  Interprovincial  League  against  Pellagra  edit 
a  magazine,  the  Rivista  Pellagrological  Italiana,  devoted 
to  the  struggle  against  the  disease.  Popular  pamphlets 
are  distributed  in  great  numbers;  popular  lectures  are 
held  everywhere;  big  colored  Hthographs,  representing  the 
healthy  laborer  fed  on  sound  com  and  the  pellagrous  laborer 
fed  on  spoiled  or  moldy  corn,  hang  on  the  walls  of  pubHc 
lecture  halls;  and  the  pellagrologic  and  agricultural  com- 
missions of  the  different  provinces  multiply  instructions 
by  both  precept  and  example.  The  results  vary  with  the 
various  districts,  but  they  are  encouraging  on  the  whole, 
and  they  coincide  with  a  marked  rise  in  general  prosperity. 
The  laborer  who  wants  to  eat  something  else  besides  com 
can  do  so  to-day  as  he  never  could  before.  Great  numbers 
of  the  rural  population  are  employed  in  factories,  where  they 
obtain  a  varied  diet.  The  effect  of  industrial  hfe  is  clearly 
shown  in  the  numerous  decrease  of  pellagrous  cases  be- 
tween the  ages  of  twenty  and  thirty;  many  Italians  spend 
the  siunmers  in  foreign  countries  as  laborers;  when  they 
return  in  the  winter,  it  is  not  only  with  a  stock  of  money 
for  the  family,  but  also  with  a  stock  of  experience.  They 
no  longer  care  to  Hve  on  polenta  only.  Their  wives  and 
daughters  who  have  stayed  at  home  may  go  on  with 
the  old  fare,  but  the  men  require  mixed  diet.  It  is  in- 
dustriaHsm  and  temporary  emigration,  far  more  than  the 


THE  PROPHYLAXIS  OF  PELLAGRA 


225 


habit  of  dining  occasionally  at  a  trattoria,  which  accounts 
for  the  predominance  of  women  over  men  among  pella- 
grins of  the  vigorous  age.  If  the  predominance  is  not  still 
more  marked,  it  is  due  to  a  contrary  tendency  among 
those  to  stay  at  home  and  work  in  the  fields.  Among 
these  classes  the  men  suffer  most;  possibly  because  they 
work  harder,  possibly  because  they  eat  more  polenta,  or 
for  both  reasons.  One  thing,  at  any  rate,  is  plain — that 
even  without  government  activity  and  private  aid  pellagra 
would  be  diminishing  in  Italy  to-day.  The  consumption 
of  meat  is  increasing  rapidly;  the  people  are  living  better, 
the  farm  laborer  gets  higher  wages,  and,  if  he  accepts  a 
part  of  his  wages  in  kind,  he  no  longer  allows  the  landlord 
to  pay  him  in  moldy  corn.  Thus,  many  causes  unite  to 
aid  the  fight  against  pellagra,  and  for  this  reason  it  is  hard 
to  say  how  much,  if  any,  of  the  progress  is  due  to  legisla- 
tive enactment. 

If  we  leave  statistics  and  listen  to  the  opinions  of  experts, 
we  shall  reach  the  conclusion  that  pellagra  in  Italy  is  de- 
creasing notably  both  in  numbers  and  in  intensity,  but  that 
it  is  extending  its  area.  The  causes  of  the  decrease  have 
been,  in  the  main,  the  improved  conditions  of  the  laboring 
classes  through  the  diversification  of  industries,  temporary 
emigration,  scientific  agriculture,  and  improved  wage  con- 
tracts; but  a  part,  at  least,  of  the  progress  is  directly  at- 
tributable to  direct  measures  of  prevention  and  cure. 

Pellagra  hospitals,  sanitary  stations,  and  food  distribu- 
tion have  lengthened  the  life  of  the  pellagrins  and  averted 
the  worst  form  of  the  disease.  Such  preventive  measures 
as  desiccating  plants  and  rural  kitchens  have  aided  in  pro- 
tecting the  peasantry  from  its  scourge.     But,  above  all, 


15 


226  PELLAGRA 

the  prohibition  of  spoiled  corn  has  had  an  immense  effect 
upon  the  public  health.  What  is  needed  is  an  extension 
of  the  government  control  to  mills  and  the  milling  industry. 
And,  while  all  ideas  of  prohibiting  corn,  either  as  a  crop  or 
as  an  article  of  food,  are  impracticable,  the  effort  to  edu- 
cate the  peasantry  in  regard  to  the  dangers  of  spoiled  com, 
and  to  show  him  substitutes  for  the  more  perilous  varieties, 
as  well  as  for  the  unwholesome  corn  loaves,  are  not  vain. 
In  education,  even  more  than  in  government  control,  Hes 
the  hope  of  pellagra's  enemies.  For  a  country  like  the 
United  States  many  of  these  measures,  educational  and 
otherwise,  would  be  just  as  appropriate  and  as  successful 
as  in  Italy.  The  lessons  learned  may  be  largely  utilized 
by  our  own  students  of  this  problem,  and  both  the 
minds  and  consciences  of  the  publicists  should  be  awak- 
ened that  some  of  these  measures  be  speedily  inaugu- 
rated. 

In  this  connection  it  may  be  of  interest  to  give  some 
recommendations  elucidated  by  Dr.  Sandwith,  and  put 
before  the  British  Government  in  the  interest  of  the  pel- 
lagra situation  in  Egypt: 

I.  That  the  village  authorities  of  Lower  Egypt  should 
be  informed  by  the  usual  methods  of  the  Ministry  of  the 
Interior  that,  although  good  maize  is  an  excellent  food,  the 
habitual  use  of  bad  maize  produces  a  disease  affecting  not 
only  the  skin,  but  also  the  digestive  and  nervous  systems. 
The  question  is  now  of  increasing  importance,  for  corn  is 
much  more  cultivated  than  it  was  a  few  years  ago,  in  conse- 
quence of  the  increase  of  the  population  and  the  more 
bountiful  supply  of  water.  On  the  other  hand,  the  wages 
of  the  fellaheen  have  nearly  doubled  during  the  last  fifteen 


THE    PROPHYLAXIS  OF  PELLAGRA 


227 


years,  and,  therefore,  they  can  now  afford  better  food,  in- 
cluding more  meat. 

II.  Maize  is  sold  at  the  weekly  market  of  every  town;  it 
is  stored  in  "  shunas  "  in  all  large  towns,  and  it  is,  in  addi- 
tion, sold  as  a  surplus  stock  by  the  fellaheen  from  their 
own  land  to  their  neighbors.  It  seems  to  be  impossible  to 
control  or  inspect  the  sale  of  maize,  but  I  think  the  local 
authorities  should  be  informed  that  it  is  improper  to  allow 
obviously  diseased  maize  to  be  exposed  for  sale.  But  it 
is  not  the  worst  maize  which  finds  its  way  into  the  market, 
for  the  worst  samples  cannot  command  a  price.  The  poor- 
est peasants  are  the  chief  offenders,  for  at  the  end  of  each 
year  their  custom  is  to  take,  in  lieu  of  some  of  their  wages,  a 
piece  of  land,  which  they  cultivate  for  themselves  with  a 
crop  of  maize;  the  most  careless  of  them  sow  diseased  seed, 
gather  the  crop  before  it  is  ripe,  store  it  in  damp  places 
before  it  is  properly  dried,  and  habitually  eat  the  worst 
ears,  which  they  cannot  sell. 

The  following  translation,  by  Babcock  and  Lavinder,  is 
an  example  of  the  kind  of  popular  pamphlets  now  being 
distributed  in  Italy,  and  some  of  the  suggestions  herein 
contained  may  be  perused  with  profit  by  health  oflScers  and 
departments  interested  in  the  subject. 

ADVICE  AND  RULES  FOR  AVOIDING  PELLAGRA 

Spoiled  com  is  a  cause  of  pellagra,  and  com  readily  be- 
comes spoiled,  moldy,  or  poisonous  when  harvested  too 
early,  before  it  is  ripe,  and  stored  in  places  which  are  damp 
and  poorly  ventilated;  it  may  also  be  of  poor  quality  when 
imported  from  some  other  place,  and  may  contain  a  large 
percentage  of  damaged  grain. 


228  PELLAGRA 

Spoiled  com  may  be  recognized  by  its  pale  or  greenish 
color,  by  the  shrivelled  and  cracked  surface  of  the  grains, 
which  are  also  covered  with  greenish,  bluish  or  brownish 
spots,  by  its  musty  odor,  and  its  bitterish  and  disgusting 
taste. 

The  damaged  com  also  weighs  less  than  sound  corn,  and 
the  surface  of  spoiled  grain  lacks  the  shining  appearance  of 
the  sound  article. 

Keep  your  com,  then,  in  places  well  dried  and  aired. 
Distrust  white  com,  because  it  is  more  Hkely  to  spoil  than 
other  kinds.     Imported  com  is  frequently  damaged. 

Keep  watch  over  your  com  while  it  is  being  ground  in 
the  mills  of  the  country. 

If  you  have  carried  good  com  to  the  miU,  see  to  it  that 
you  receive  meal  ground  from  that  com,  and  do  not  aUow 
the  miller  to  substitute  meal  ground  from  inferior  grain. 

If  your  com  is  ground  by  a  roUer  mill,  the  spoiled  grains 
are  not  likely  to  be  ground  into  the  meal. 

Instead  of  spending  your  money  on  wines  and  liquors, 
buy  wheat  bread;  limit  your  use  of  polenta.  If  you  have 
milk,  eggs,  cheese,  limit  the  sale  of  these  articles  to  others, 
and  use  at  least  a  part  of  such  products  for  your  own  home 
food. 

Do  not  be  ashamed  to  go  to  the  doctor  if  you  are  a  pel- 
lagrin, and  have  yourself  entered  at  the  local  sanitarium  or 
at  the  economic  kitchen.  Get  cured  in  time,  and  so  avoid 
the  hospital  or  the  insane  asylum. 

Remember  that  pellagrins  require  a  curative  diet.  It  is 
your  right  to  demand  it,  and  your  duty  to  procure  it. 

The  cleanhness  and  healthfulness  of  your  homes  are 
necessary  conditions  for  preventing  the  molding  of  com 


THE  PROPHYLAXIS  OF  PELLAGRA        229 

which  is  kept  in  your  houses.  Never  keep  your  com  in 
bed-rooms,  and  see  to  it  that  you  have  proper  places  for 
the  stowing  and  seasoning  of  your  grain. 

Keep  the  corn  dry. 

Exert  yourselves  to  co-operate  with  others  for  your  own 
salvation  by  acquiring  knowledge  of  and  interest  in  the 
application  of  the  law  against  pellagra. 

As  in  this  country  pellagra  has  proved  itself  a  disease  of 
the  educated  and  well-to-do  classes,  in  addition  to  the 
poor  and  uneducated,  some  of  the  above  would  possibly 
be  inapphcable;  some  of  it,  however,  would  apply  to  our 
people,  and  such  portions  might  be  used  to  advantage. 

The  writer  recognizes  the  wholesomeness  and  healthful- 
ness  of  sound  and  matured  corn.  When  the  "  pedigree  " 
of  the  com  is  known,  when  it  has  been  allowed  to  properly 
dry,  and  has  been  stored  in  sanitary  receptacles,  ground 
without  contamination  with  spoiled  grain,  and  the  meal 
protected  against  dampness  or  mold,  no  more  eligible 
food-stuff  can  be  named,  possessing  as  it  does  an  abundance 
of  sustaining  food  elements.  When,  on  the  other  hand,  it 
is  allowed  to  "  spoil,"  to  generate  suspicious  toxins,  or  to 
become  an  abiding  place  for  the  various  molds  and  bacteria, 
corn  then  becomes  an  enemy,  one  to  be  both  avoided  and 
fought. 

Other  prophylactic  measures  consist  in  the  ingestion  of  a 
liberal,  varied,  and  well-balanced  dietary— one  containing 
an  abundance  of  the  flesh  proteins  in  fresh  form,  and  the 
legumes  also  in  a  wholesome  form. 

The  studies  of  the  Thompson-McFadden  Commission 
have  conclusively  shown  the  infinitely  greater  spread  of 
pellagra  in  the  absence  of  proper  facilities  for  disposing  of 


230  PELLAGRA 

sewage.  Wherever  possible,  a  water-carriage  system  should 
be  employed,  and  where  this  is  not  practicable,  all  precau- 
tions for  screening  and  otherv\dse  rendering  innocuous  the 
human  excreta  should  be  practised.  Pellagra  certainly 
flourishes  in  unsanitary  surroundings. 

The  writer  trusts  that  the  physicians  who  read  this  book 
may  feel  constrained  to  aid  in  the  enforcement  of  the  pure 
food  laws,  and  to  hold  up  the  hands  of  those  to  whom  the 
enforcement  of  these  laws  is  their  duty. 

The  various  law-making  bodies  should  also  be  memo- 
rialized to  so  strengthen  and  amend  our  laws  that  corn  may 
be  frequently  inspected  in  its  journey  from  the  field  to  the 
table,  so  that  it  may  reach  the  masses  of  our  people  in  a 
harmless  and  wholesome  condition. 

The  mass  of  the  American  citizens  may  be  trusted  to  do 
right  if  it  is  only  presented  in  a  proper  manner,  and  when 
the  people  at  large  wake  up  to  a  full  realization  of  the  grav- 
ity of  the  situation  now  confronting  us,  we  may  expect,  as 
did  our  distant  friends,  that  wise  and  beneficient  laws  wiU 
be  put  on  our  statute  books,  and  enforced  in  ever>'  nook  and 
comer  of  this  broad  land,  that  will  make,  in  the  not  distant 
future,  a  fading  memory  of  pellagra,  an  American  problem 
that  was  successfully  and  effectually  solved. 


CHAPTER  X 

DESCRIPTIONS  OF  SOME  RECENT  EXPERIMENTS 
ON  ANIMALS,  AND  DEDUCTIONS  THEREFROM 

This  somewhat  supplementary  chapter  will  enter  mto 
a  discussion  of  some  recent  experiments  on  animals,  in  the 
effort  to  arrive  at  a  clearer  knowledge  of  the  etiology  of 
pellagra.  These  accounts  are  from  Public  Health  Reports 
issued  by  the  Public  Health  and  Marine-Hospital  Service, 
and  reflect  much  credit  on  the  able  and  scientific  members 
of  the  service. 

The  first  is  an  abstract  from  a  report  by  Dr.  C.  H.  Lav- 
inder,  entitled  ''  Pellagra  and  its  Possible  Relation  to  Maize 
According  to  Some  Recent  Views,"  issued  February  24, 
1911. 

Raubitschek  seems  to  have  been  the  first  to  take  up,  in 
an  experimental  way,  the  question  as  to  the  effects  of  ex- 
posure to  sunlight  upon  maize-fed  animals  in  association 
with  the  question  of  a  possible  relation  to  the  etiology  of 
pellagra.  His  first  communication  was  apparently  of  a 
more  or  less  preliminary  character,  and  quite  recently  he 
has  published  a  much  more  important  paper  upon  the  sub- 
ject. 

It  is  the  purpose  of  the  present  article  to  review  briefly 
this  paper,  as  well  as  the  papers  of  two  other  authors  on 
the  same  subject,  and  to  add  a  few  details  on  certain  mat- 
ters germain  to  the  views  expressed. 

231 


232  PELLAGRA 

In  his  last  paper,  above  mentioned,  Raubitschek,  in  his 
introduction,  notes  the  immense  mass  of  literature  which 
has  accumulated  on  the  etiology  of  pellagra,  and  speaks  in 
the  harshest  terms  of  the  very  questionable  kind  of  work 
which  has  been  done  in  this  field. 

He  also  comments  on  the  fact  that  only  seldom  have  the 
somewhat  scanty  results  of  pathologico-anatomic  results 
been  employed  in  attempts  to  clear  up  its  etiology,  and  that 
modern  microbiologic,  especially  serologic,  technic  has  never, 
to  any  extent,  been  so  used.  The  work  which  has  been 
done,  he  adds,  is  composed  in  great  part  of  misinterpreted 
researches  on  the  feeding  of  animals,  incomplete  metabolic 
investigations,  and  the  piling  up  of  statistical  details. 

After  very  briefly  mentioning  some  of  the  Hterature,  he 
places  the  theories  of  the  etiology  of  pellagra  in  three 
groups:  the  bacterial,  toxic,  and  autotoxic.  These  theories 
are  then  briefly  reviewed  in  a  general  way,  and  he  concludes 
that  not  one  of  them  in  its  present  state  can  be  consid- 
ered satisfactory. 

Finally,  he  observes  that  if  the  real  cause  of  pellagra  is 
unknown,  we  must  not  insist  too  closely  upon  bringing  the 
disease  into  strict  causal  relation  with  the  use  of  maize  as 
food,  and  that,  if  any  real  progress  is  to  be  made,  the  above 
theories  must  be  tested  in  a  satisfactory  experimental  way, 
especially  upon  the  pellagrin,  before  they  can  be  accepted 
as  of  real  importance. 

He  then  in  several  sections  takes  up  his  own  experimental 
researches. 

He  found  it  possible  to  study  only  briefly  the  numerous 
micro-organisms,  which  have  been  isolated  from  both 
good  and  spoiled  maize  by  various  workers,  and  presented 


EXPERIMENTS  ON  ANIMALS  AND  DEDUCTIONS      233 

as  the  cause  of  pellagra.  The  numerous  molds  which  can 
be  especially  grown  from  spoiled  corn  met  the  same  fate. 
Since  raw  corn  is  not  directly  consumed  as  food,  but  only 
products  prepared  from  it,  he  deemed  the  bacteriologic 
investigation  of  prepared  (cooked)  food  worthy  of  more 
consideration  than  the  raw  material. 

Nevertheless,  in  a  preliminary  investigation,  largely  as 
a  matter  of  orientation,  he  did  take  up  in  a  general  way  the 
flora  of  raw  maize,  and  compared  his  results  with  the  lit- 
erature. He  thought  certain  isolated  cultures  which  ex- 
hibited a  tolerance  to  high  temperatures  were  of  a  special 
importance  in  consideration  of  the  cooking  of  food. 

The  various  bacteria  and  molds  were  too  numerous  for 
detailed  study,  so  he  soon  confined  himself  to  work  on  food 
prepared  from  maize,  especially  since  he  found  that  rela- 
tively few  of  the  micro-organisms  withstood  a  temperature 
of  100°  C.  Such  micro-organisms  suggested  a  line  of  work 
looking  to  the  establishment  of  an  infection  of  the  gastro- 
intestinal tract  by  food  prepared  from  corn. 

With  this  end  in  view,  he  prepared  polenta  and  cakes 
from  both  good  and  bad  corn.  These  preparations  were 
opened  under  sterile  precautions,  and,  from  the  inside,  cul- 
tures were  made  on  suitable  media,  and  grown  mostly 
under  aerobic  conditions.  In  a  few  cases  he  recovered 
some  species  of  Penicillium  and  Aspergillus,  but  chiefly  the 
Bacterium  maidis.     Usually  his  cultures  were  sterile. 

Next  he  turned  to  the  bacteriologic  investigations  of 
pellagrins  themselves,  and  in  this  work  he  kept  especially 
in  mind  the  ideas  of  Ceni  on  aspergillary  infections  as  a 
cause  of  pellagra. 

Blood-cultures  from  an  arm  vein  were  made  from  pella- 


234  PELLAGRA 

grins  in  all  stages  of  the  malady,  and  his  results  were  con- 
stantly and  invariably  negative.  Bacteriologic  investiga- 
tions of  the  stools  of  pellagrins  convinced  him  that  the  in- 
testinal flora  of  pellagrous  persons  differed  in  no  essential 
way  from  that  of  healthy  individuals.  At  first  there  ap- 
peared to  be  an  unusual  occurrence  of  the  Bacterium  maidis 
in  pellagrous  stools,  but  further  work  showed  this  bacte- 
rium to  be,  in  summer,  just  as  frequent  in  the  stools  of 
healthy  persons,  possibly  as  the  result  of  the  consumption 
of  such*  raw  foods  as  salads,  etc. 

Finally,  bacteriologic  investigations  of  the  organs  of 
pellagrins  a  few  hours  after  death  gave  essentially  negative 
results. 

He  concluded,  therefore,  that  there  exists  no  basis  for 
a  parasitic  etiology  of  pellagra. 

Under  the  idea  that  pellagra  is  due  to  an  almost  exclu- 
sive maize  diet,  he  thought  the  possible  appearance  of 
specific  antibodies  in  the  blood-serum  of  pellagrins  a  mat- 
ter of  much  importance. 

Accordingly,  he  prepared  maize  extracts,  and  tried,  with 
proper  technic,  to  obtain  "precipitin"  reaction  in  blood- 
sera  collected  from  numerous  pellagrins  in  all  stages  of  the 
disease.  The  results  were  always  positive.  In  this  control 
work,  however,  with  both  healthy  persons  and  animals, 
he  obtained  the  same  result.  Hence  he  concluded  that  this 
reaction  possesses  neither  diagnostic  nor  biologic  value. 
He  omitted  detailed  protocols  as  useless  and  unnecessary. 

In  similar  manner  he  also  made  use  of  the  complement- 
fixation  reaction,  and  here  again  nothing  characteristic 
could  be  observed.  His  controls  displayed  the  same  result 
seen  with  the  sera  of  pellagrins — viz.,  absence  of  hemolysis. 


EXPERIMENTS  ON  ANIMALS  AND  DEDUCTIONS       235 

Next,  he  tried  experiments  for  hypersusceptibility  in 
pellagrins  and  in  healthy  persons  by  means  of  the  ophthal- 
mo-  and  cutaneo-reactions  with  various  maize  extracts. 
All  of  these  results  were  negative. 

These  experiments,  he  says,  still  leave  room  for  proof 
how  pellagrins,  fed  for  a  short  time  on  a  good  mixed  diet, 
would  react  to  a  suddenly  administered  maize  diet. 

It  also  remains  to  be  shown  whether  pellagrins,  on  a 
long-continued  maize  diet,  may  be  sensitized  from  the  in- 
testinal tract,  and  whether  they  would  react  from  a  new 
supply  of  maize  albumin  with  the  important  symptoms  of 
hypersensitization,  such  as  vertigo,  fever,  vomiting,  and 
diarrhea,  all  of  which  are  important  if  pellagra  has  any 
causal  relation  with  a  maize  diet. 

Still  it  is  evident  that  both  sound  persons  and  pellagrins 
bear  a  short  exclusive  maize  diet  without  reaction. 

Further  experiments  were  made  upon  the  phenomena  of 
anaphylaxis  in  animals  to  determine  the  presence  of  maize 
antibodies.  Pellagrins  in  all  stages  of  the  disease  were 
bled  from  a  vein  of  the  arm,  and  these  sera  in  various  quan- 
tities (5  to  10  c.c.)  were  injected  intraperitoneally  into 
guinea-pigs.  Twenty-four  hours  later  intravenous  injec- 
tions of  the  same  sera  (up  to  3  c.c.)  were  made  into  these 
pigs.  These  animals  showed  reactions  not  observably  dif- 
ferent from  the  controls  injected  with  sera  from  normal 
persons. 

He  concludes  from  the  work  of  this  section  that  antibodies 
specific  for  maize  albumins  (from  good  or  bad  maize)  do 
not  occur  in  the  serum  pellagrins.  If  these  negative  results 
do  not  permit  any  definite  conclusion,  still  it  would  appear 
that  from  them  one  may  infer  that  any  causal  relation 


236  PELLAGRA 

between  the  maize  diet  (good  or  bad)  and  pellagra  is  pure 
speculation. 

In  his  experiments  concerning  toxins  he  sought  to  deter- 
mine whether  maize,  naturally  or  artificially  spoiled,  would 
produce  deleterious  effects  upon  animals  if  used  in  rational 
doses. 

For  this  purpose  he  made  use  of  good  com  and  spoiled 
com  obtained  from  pellagrous  regions,  ground  under 
proper  precautions,  and  extracted  for  twenty-four  hours  in 
sterile  tap-water.  He  also  made  extracts  from  a  maize 
porridge  or  broth  which  had  been  inoculated  with  various 
pure  cultures,  isolated  either  from  bad  maize  or  pellagrous 
stools. 

The  extracts  he  obtained  were  variously  colored,  and 
some  possessed  a  fatty-acid-like  odor.  They  were  kept  a 
long  while  in  the  ice-chest  under  toluol  without  apparently 
undergoing  further  change. 

With  these  extracts  he  mjected  rabbits  (subcutaneously, 
intraperitoneally,  and  intravenously),  mice,  and  guinea- 
pigs  (subcutaneously  and  intraperitoneally) .  In  one  series 
he  used  large  doses,  up  to  8  c.c. ;  in  another  series  daily  small 
subcutaneous  doses  for  one  to  two  weeks;  in  another  series 
various  extracts  were  daily  mixed  with  the  food  of  the 
animals. 

In  no  case  were  changes  observed  which  by  any  means 
could  be  brought  to  show  any  causal  relation  between 
pellagra  and  a  maize  diet.  Frequently  the  animals  refused 
the  food,  and  hence  lost  weight,  but  in  no  way  did  the  ex- 
periments justify  any  idea  whatever  that  com  contained  a 
toxic  substance  which  by  long  use  may  lead  to  pellagroid 
phenomena  in  animals. 


EXPERIMENTS   ON   ANIMALS   AND   DEDUCTIONS       237 

He  concluded  that  the  negative  results  of  these  experi- 
ments are  worthy  of  note,  since  it  would  appear  from  them 
that  not  one  of  the  above-mentioned  theories  is  supported 
by  these  results,  and  not  one  seems  to  bear  comparison 
with  actual  facts. 

In  continuing  this  discussion,  Raubitschek  points  out 
that  the  pellagrous  erythema  is  usually  confined  to  the  ex- 
posed surfaces  of  the  body,  and  thinks  that  from  this  it 
may  be  inferred  either  that  there  is  a  reduced  resistance  of 
the  entire  body  surface,  and  hence  exposed  parts  are  unduly 
sensitive  to  slight  noxious  influences  (sunlight),  or  that 
eventually,  under  a  maize  diet  in  the  body  surfaces  exposed 
to  sunlight,  there  is  developed  a  noxious  substance  (noxe) 
which  produces  not  only  local  morbid  changes,  but  also 
affects  the  entire  organism.  This  thought  is  further  justi- 
fied by  the  usual  occurrence  of  pellagrous  skin  changes  at 
that  season  when  the  field  laborer  is  most  exposed  to  the 
sun.  It  is  possible,  then,  that  there  may  be  some  relation 
between  a  maize  diet,  sunlight,  and  pellagra. 

He  directs  attention  to  the  analogy  with  buckwheat 
poisoning  (fagopyrismus)  in  animals.  In  this  connection 
white  or  spotted  animals,  exposed  to  the  light,  suffer,  while 
the  dark  animals  or  white  animals,  kept  in  the  dark,  es- 
cape. In  this  condition  general  as  well  as  local  symptoms 
are  noticed. 

The  active  body  in  the  buckwheat  is  soluble  in  organic 
solvents,  and  seems  to  be  a  lipoid,  in  the  wide  sense,  and  is 
possibly  related  to  the  vegetable  lipochromes. 

All  these  phenomena  stand  in  near  relation  to  the  so- 
called  photodynamy — viz.,  that,  under  the  influence  of  cer- 
tain fluorescent  color  stuffs,  the  effect  of  light  on  exposed 


238 


PELLAGRA 


body  surfaces  in  animals  is  to  produce  erythema  and  other 
skin  changes,  with  eventual  death  of  the  animal.  It  would 
seem,  then,  that  some  such  idea  may  be  entertained  for  a 
similar  relation  of  things  in  pellagra,  for  in  corn  there  occurs 
a  fluorescent  color  stuff,  and  in  bad  corn  is  also  found  a 
characteristic  red  material.  This  idea  opens  up  a  new 
field  for  investigation. 

Raubitschek  then  describes  a  number  of  experiments 
on  animals,  testing  as  to  maize  diet  and  exposure  to  sun- 
light; as  to  the  effects  of  the  quality  of  the  maize;  the  effects 
of  increased  intensity  of  light;  the  effects  of  change  of  diet 
after  appearance  of  symptoms;  the  effects  of  a  diet  of  fat- 
free  maize,  and  the  effect  of  feeding  maize  fat. 

His  figures  are  voluminous,  and  some  of  his  data  quite 
difficult  to  comprehend.  He,  however,  arrives  at  certain 
conclusions,  which  will  be  stated.  He  thinks  he  has  demon- 
strated the  presence  of  a  photodynamic  stuff  in  maize, 
and  that  this  material  is  soluble  in  alcohol.  He  brings  out 
strongly  the  effect  upon  the  animals  of  changing  the  con- 
ditions of  life  without  any  modification  of  diet,  and  discusses 
the  s3anptoms  displayed  by  the  animals. 

He  declares  that  he  does  not  attempt  to  bring  his  experi- 
mental results  into  a  strict  relation  with  the  etiology  of 
pellagra,  nor  to  assume  for  this  disease  a  photodynamic 
basis,  or  even  to  conclude  that  pellagra  is  produced  by  an 
almost  exclusive  diet  of  maize,  good  or  bad,  which  displays 
its  harmful  effects  first  under  the  influence  of  light.  The 
inference  is  apparent  that  his  results  are  very  suggestive, 
but  not  as  yet  conclusive. 

He  comments  on  certain  feeding  experiments  of  other 
workers,  and  points  out  that  the  conditions  of  life  under 


EXPERIMENTS  ON  ANIMALS  AND   DEDUCTIONS       239 

which  their  animals  were  kept  may  explain  some  of  their 
irregular  results. 

He  notes  the  effect  of  rice  diet  on  his  animals,  and  says 
this  cereal  also  is  rich  in  fat,  and  by  many  is  held  account- 
able for  a  disease  somewhat  analogous  to  pellagra — viz., 
beriberi. 

In  further  discussing  his  conclusions,  he  says  that  the 
possibility  should  be  borne  in  mind  that  pellagra  and 
pellagroid  affections  may  be  due  not  only  to  the  use  of 
maize  as  a  food,  but  also  to  the  use  of  other  grains  or  other 
plant  stuffs  which  are  eaten  in  various  localities.  Hence, 
observations  at  various  places  and  at  various  times  might 
help  to  explain  the  vexed  question  of  a  "  pellagra  without 
maize." 

This  phase  of  the  etiology  of  pellagra  has  not  as  yet 
attracted  very  much  attention  in  America  or  English  lit- 
erature, but  is  worth  considering,  especially  as  the  subject 
is  still  sub  judice. 

Lavinder  comments  on  Raubitschek's  experimental  labors, 
but  does  not  commit  himself.  As  he  remarks,  the  question 
of  photodynamic  substances  and  their  effects  is  a  large  one, 
with  a  rather  extensive  literature.  References  have  already 
been  given  to  some  of  this.  It  may  be  briefly  said,  in  a 
general  way,  that  a  great  number  of  flourescent  bodies, 
both  vegetable  and  animal,  which  are  harmless  in  the  dark, 
have  been  shown  to  possess  highly  toxic  properties  in  the 
light,  especially  direct  sunlight.  These  properties  include 
the  power  of  exerting  a  deleterious  influence  on  animal 
body  cells  and  on  certain  protozoa.  In  this  series  of  sub- 
stances are  found  normal  constituents  of  the  animal  body, 
such  as  hematoporphyrin. 


240  PELLAGRA 

Fagopyrismus  is  an  interesting  condition  which  arises  in 
white  or  white-spotted  animals  fed  on  buckwheat  and  ex- 
posed to  the  sunHght.  It  does  not  develop  in  dark  ani- 
mals nor  in  white  animals  kept  away  from  the  Hght.  It 
is  not  due  to  the  buckwheat,  but  to  other  species  of  poly- 
gonum, and  may  arise  from  the  eating  not  only  of  the  green 
plant,  especially  at  the  time  of  flowering,  but  also  of  the 
grains,  straw,  stubble,  and  chaff.  It  occurs  especially  in 
lambs  and  swine,  more  rarely  in  cattle,  and  very  rarely  in 
horses.  The  symptoms  will  return  even  three  or  four  weeks 
after  discontinuance  of  the  food  if  the  animal  be  exposed 
to  strong  sunlight.  In  the  winter  the  eruption  is  restricted 
to  a  mere  itching  and  burning. 

The  symptoms  consist  of  a  severe  erythema  of  the  skin 
or  even  a  severe  dermatitis,  and  there  may  be  an  associated 
disturbance  of  respiration,  with  general  symptoms  referable 
to  the  central  nervous  system,  more  particularly  if  the  skin 
around  the  head  be  involved.  There  seems  to  be  some 
question  as  to  whether  the  condition  is  caused  by  certain 
irritant  products  exerting  only  a  local  action  on  the  skin, 
with  secondary  general  manifestations,  or  whether  it  is  due 
to  some  toxic  substance  produced  in  the  body  of  the  animal 
under  the  influence  of  sunHght. 

Experimental  work  on  laboratory  animals,  however, 
seems  to  show  clearly  that  there  is  developed  some  toxic 
substance  in  the  body  of  the  animal.  Ohmke  fed  rab- 
bits, mice,  and  guinea-pigs  on  buckwheat,  and  death  re- 
sulted in  the  white  animals  exposed  to  diffused  sunlight. 
The  symptoms  were  loss  of  hair,  paralytic  phenomena, 
and  disturbances  of  respiration.  White  animals  kept  in 
the  dark  and  the  gray  animals  showed  no  changes. 


EXPERIMENTS  ON  ANIMALS  AND   DEDUCTIONS      241 

The  chaff  as  well  as  the  grains  gave  the  same  result. 
Alcoholic  extracts  of  the  buckwheat  showed  a  noticeable 
fluorescence,  and  proved  just  as  harmful  as  the  buckwheat, 
while  the  buckwheat  left  after  extraction  was  harmless. 

Buckwheat  poisoning  in  man  seems  to  have  been  very 
rarely  noted,  and  it  may  be  said  that  we  know  very  little 
of  buckwheat  poisoning  in  the  human  species. 

The  relation  between  the  pellagrous  erythema  and  ex- 
posure to  sunlight  has  always  attracted  attention  among 
those  interested  in  this  disease,  and  there  seems  to  be  no 
doubt  that  some  such  relation  does  exist.  This  relation  is, 
however,  not  always  a  very  definite  one.  Pellagrous 
erythemata  are  not  usual,  but,  at  the  same  time,  are  not 
uncommon  on  covered  parts  of  the  body,  and  Neusser  long 
ago  observed  that  in  the  gypsy  children  of  Roumania,  who 
go  about  naked,  the  pellagrous  erythema  is  usually  confined 
to  local  situations — hands,  feet,  and  face.  It  is  worthy  of 
note  also  that  the  dark-skinned  races  suffer  from  pellagra 
and  from  its  erythema,  and  that  the  negro  of  the  Southern 
States  exhibits  erythemas  just  as  extensive  and  just  as 
severe  as  those  seen  in  the  whites. 

If  the  coloring-matters  of  corn  are  of  such  importance  as 
implied  above,  then  it  is  likely  that  the  varieties  may  be  a 
matter  of  importance.  The  Italians,  in  their  prophylactic 
measures,  have  come  to  regard  the  yellow  varieties  as  less 
likely  to  undergo  spoiling,  and  they  condemn  the  use  of 
white  varieties.  White  varieties  of  corn  are  rarely  seen  in 
Italy. 

With  regard  to  beriberi  and  rice,  it  is  interesting  to  note 
that  Fraser  and  Stanton,  in  their  experimental  work  of 
feeding  fowls  with  rice,  state  that  alcohol-extracted  rice 

16 


242  PELLAGRA 

produced  the  same  phenomena  as  the  rice  before  such  extrac- 
tion, and  that  rice  which  has  been  proved  harmless,  after 
being  extracted  with  alcohol,  produced  typic  phenomena 
in  fowls,  but  that  if  a  quantity  of  the  extract,  freed  of  alco- 
hol, were  given  at  the  same  time  the  birds  remained  well. 

Finally,  it  is  to  be  remarked  that  the  results  of  feeding 
experiments  upon  animals  are  very  difficult  of  interpreta- 
tion, and  conclusions  can  be  drawn  therefrom  only  with  the 
uttermost  caution. 

Feeding  experiments  with  maize,  made  by  workers  in- 
terested in  pellagra,  have  produced  many  discordant  re- 
sults and  varied  interpretations.  To  apply  results  of  this 
kind  to  the  explanation  of  a  specific  disease  of  man  is  diffi- 
cult and  uncertain.  Such  application  must  be  made  from 
wide  knowledge,  broad  experience,  and  good  judgment. 

For  the  purpose  of  further  elucidating  these  experiments 
Dr.  Lavinder  issued  a  note  regarding  some  experiments 
gone  into  by  him,  and  his  comments  were  issued  in  a  bulletin 
published  May  5,  191 1.  The  following  is  abstracted  from 
his  note: 

For  the  purpose  of  confirming  these  observations  certain 
experiments  were  begun  February  24th  and  terminated 
April  27,  191 1. 

Cages  containing,  first,  2  white  rabbits  and  i  dark  one; 
second,  4  white  guinea-pigs  and  2  dark  ones ;  third,  6  white 
mice;  and,  fourth,  4  white  rats,  were  placed  in  diffused 
sunhght,  and  the  animals  were  fed  upon  a  diet  of  corn  and 
green  food  (cabbage,  etc.),  in  approximately  a  proportion 
of  4  of  the  former  to  i  of  the  latter.  Control  cages  on  a 
mixed  diet  were  placed  along  with  the  others.     All  animals 


EXPERIMENTS  ON  ANIMALS   AND   DEDUCTIONS       243 

received  water  freely.  An  exactly  similar  series  of  ani- 
mals on  the  same  diet  were  placed  in  almost  absolute  dark- 
ness. 

The  corn  used  in  feeding  the  animals  was  yellow  grain 
of  fairly  good  quality,  and  showed  no  marked  evidence  of 
spoiHng. 

For  the  first  few  days  it  was  given  uncooked;  later,  it 
was  cooked  into  cakes,  and  this  the  animals  seemed  to  pre- 
fer. It  was  noticed  that  unless  great  care  was  used  in 
storing  it  the  corn  readily  became  moldy. 

Along  with  the  other  animals  in  diffused  daylight  was 
placed  a  cage  containing  3  pigeons,  2  dark  colored  and  i 
white  spotted.  These  were  fed  on  an  exclusive  diet  of 
corn  which  showed  marked  evidence  of  spoiling.  They 
were,  of  course,  given  water. 

Generally  speaking,  the  results  of  these  experiments  were 
entirely  negative.  There  were  several  accidental  deaths 
among  the  animals,  but  none  displayed  any  such  symptom- 
atology as  has  been  described  by  the  writers  referred  to. 
All  of  the  animals  except  the  mice  did  very  well  on  the 
corn  and  green  food  diet,  but  did  not  gain  as  much  in  weight 
as  did  the  control  animals.  A  number  of  the  mice  died 
both  in  the  control  and  in  the  other  cages,  but  without  dis- 
playing any  characteristic  phenomena.  They  were  all 
young  mice,  and  did  not  thrive  in  any  of  the  cages. 

The  pigeons  on  spoiled  corn  were  full  grown  and  showed 
no  gain  in  weight.     They  remained  well. 

No  differences  of  consequence  were  noted  between  the 
animals  kept  in  the  dark  and  those  exposed  to  the  Hght. 

Dr.  John  F.  Anderson,  Director  of  the  Hygienic  Labora- 
tory, and  Dr.  Joseph  Goldberger,  Past  Assistant  Surgeon, 


244  PELLAGRA 

have  issued  a  recent  bulletin  describing  an  attempt  to  infect 
the  rhesus  monkey  with  blood  and  spinal  fluid  from  pella- 
grins.    Their  account  is  given  verbatim: 

In  the  literature  of  pellagra  there  is  not,  so  far  as  we 
are  aware,  any  record  of  an  attempt  to  infect  by  inocula- 
tion any  of  the  higher  animals,  such  as  monkeys,  with  the 
blood  or  tissues  from  pellagrins. 

Sambon's  theory  of  the  transmission  of  pellagra  by  the 
buffalo  gnat,  or  Simulium  reptans,  would  seem  to  require 
that  the  infecting  agent  in  pellagra  be  present  in  the  blood 
at  some  stage  of  the  disease.  From  this  it  follows  that,  if 
monkeys  are  susceptible,  the  inoculation  of  blood  from 
cases  of  the  disease  should  produce  pellagra,  provided  the 
blood  was  drawn  at  a  time  when  the  infectious  agent  was 
present  therein. 

During  the  summer  of  1910  we  had  the  opportunity  of 
obtaining  some  blood  from  two  well-marked  cases  of  pel- 
lagra and  spinal  fluid  from  one  of  them.  The  blood  and 
spinal  fluid  were  used  for  the  inoculation  of  Macacus  rhesus 
monkeys.  The  details  of  the  experiments  are  given  in  the 
following  protocols: 

Case  I. — Female,  G.  M.  This  patient  was  a  well-marked 
case  of  pellagra,  showing  the  acute  manifestations  of  the 
disease  at  the  time  the  blood  was  taken.  She  was  probably 
in  her  first  attack.  Her  temperature  at  the  time  the  blood 
was  drawn  was  normal. 

July  i6th,  at  II  A.  M.,  about  10  c.c.  of  blood  was  drawn 
from  the  arm  vein,  defibrinated,  and  used  as  follows: 

Cultures  were  made  in  fermentation  tubes,  which  re- 
mained sterile. 

Monkey  No.  i,  female  rhesus.     At  12  noon  5  c.c.  of  the 


EXPERIMENTS  ON  ANIMALS   AND  DEDUCTIONS      245 

defibrinated  blood  from  G.  M.  was  inoculated  intraperi- 
toneally. 

Monkey  No.  2,  female  rhesus.  To  the  fibrin  and  blood 
remaining  in  the  flask  in  which  the  blood  was  defibrinated 
5  c.c.  of  normal  salt  solution  was  added.  The  flask  was  well 
shaken,  7  c.c.  of  the  fluid  drawn  ofi',  and  inoculated  intra- 
peritoneally. 

The  temperature  of  both  these  animals  was  taken  daily 
until  October  21,  1910,  when  the  taking  of  the  temperature 
was  discontinued,  but  the  animals  were  kept  under  obser- 
vation until  March  i,  191 1. 

On  August  II,  191 1,  there  was  noted  an  apparent  bronz- 
ing of  the  face  and  a  pinkish  tint  of  the  neck  and  upper  chest 
of  monkey  No.  i.  This  bronzing  and  tinting  was  noted  to 
be  more  distinct  on  some  days  and  at  times  of  day  than 
at  other  times.  It  persisted  for  a  long  time  without  ap- 
parent increase.  Nothing  unusual  was  noted  with  monkey 
No.  2. 

Case  2. — Female,  Mrs.  G.  This  patient  had  a  well- 
marked  case  of  pellagra,  with  a  marked  erythema  of  hands 
and  elbows  and  a  roughened,  seal)/-  forehead.  The  history 
was  unsatisfactory,  but  the  conclusion  was  reached  that 
she  was  probably  in  her  second  or  third  attack.  When  the 
blood  and  spinal  fluid  were  taken  the  patient  was  in  a  low 
muttering  delirium  and  her  temperature  was  between  101.4° 
and  102.4°  F. 

On  August  24,  1910,  at  10:  30  a.  m.  blood  was  drawn  from 
the  arm  vein  and  defibrinated.  Cultures  were  made  and 
found  to  be  sterile.  At  10:  45  a.  m.  about  11  c.c.  of  spinal 
fluid  was  withdrawn.  Cultures  were  made  in  fermentation 
tubes  and  found  to  be  sterile. 


246  ■      PELLAGRA 

Monkey  No.  3,  female  rhesus.  At  12:  10  p.  m.  inocu- 
lated with  6  c.c.  of  the  defibrinated  blood  intraperitoneally. 

Monkey  No.  4,  male  rhesus.  At  12  :  05  p.  m.  inoculated 
with  6  c.c.  of  the  defibrinated  blood  intraperitoneally. 

Monkey  No.  5,  female  rhesus.  At  11 :  55  a.  m.  inoculated 
with  10  c.c.  of  the  spinal  fluid  intraperitoneally. 

Daily  temperatures  were  taken  of  all  three  of  the  mon- 
keys until  October  21,  1910,  when  the  taking  of  tempera- 
tures were  discontinued.  The  observations,  however, 
were  continued  until  about  March  i,  191 1. 

None  of  the  monkeys  presented  anything  worthy  of 
note,  except  that  it  was  thought,  about  September  15th, 
that  monkey  No.  3  showed  a  slight  reddening  of  the  skin 
in  the  region  of  the  eyebrows.  This,  however,  lasted  only 
a  few  days. 

During  the  entire  time  the  monkeys  were  kept  under 
observation  they  were  in  a  well-lighted  room  and  exposed 
to  a  certain  amount  of  sunlight  on  bright  days.  Their 
food  was  that  given  to  other  monkeys  in  the  laboratory,  it 
not  being  considered  advisable  to  make  any  change  in 
their  diet,  as  the  question  it  was  wished  to  determine  by 
the  inoculation  of  the  fluids  from  the  cases  of  pellagra  was  as 
to  whether  the  blood  or  the  spinal  fluid  from  such  cases, 
when  inoculated  into  monkeys,  was  able  to  produce  pel- 
lagra in  these  animals. 

Summary. — The  blood  from  2  cases  of  pellagra  and  the 
spinal  fluid  from  one  of  them  were  not  infective  for  the 
rhesus  monkeys. 

Interpretation. — The  foregoing  results  permits  of  several 
interpretations.  Thus  it  may  be  (i)  that  the  rhesus 
monkey  is  not  susceptible  to  pellagra;  or  (2)  if  susceptible. 


EXPERIMENTS  ON  ANIMALS  AND   DEDUCTIONS      247 

(a)  that  our  technic  in  some  respects  was  faulty,  or  {b) 
that,  while  the  technic  was  adequate,  the  infective  agent 
was  not  present  in  the  blood  or  in  the  spinal  fluid  at  this 
stage  of  the  disease. 

Extending  this  last  interpretation,  one  may  suspect 
that  the  infective  agent  in  pellagra  never  resides  in  the  blood 
or  spinal /wi J.     A  final  conclusion,  however,  is  not  justified. 

The  writer  of  this  book  regrets  that  the  agent  etiologically 
responsible  for  pellagra  has  not  been  found  beyond  a  per- 
adventure. 

From  the  army  of  earnest  students  now  in  quest  of 
this  etiologic  agent  much  may  be  expected,  and,  while  we 
are  zealously  endeavoring  to  cope  with  the  situation  as  it 
confronts  us  in  this  country,  especially  in  the  South,  we 
look  forward  to  a  good  day  in  the  not-too-distant  future 
when  doubt  will,  give  way  to  certainty,  and  hypothesis  will 
become  assured  fact,  Gibraltar-like  in  its  foundation. 


BIBLIOGRAPHIC  INDEX 


ACHUCARO,  159 

Adoardi,  14 

Akssandrini  and  Scala,  71 

Allen,  104 

Alphonse  de  CandoUe,  35 

Anderson  and  Goldberger,  243 

Antonini,  iii 

Antonini  and  Marianni,  188 

Aubert,  116 

Babcock,  13,  27,  33,  6s,  80,  85, 
93, 109, 116, 117, 124, 139,  188, 
Babcock  and  Lavinder,  227 
Babcock  and  Watson,  23 
Babes,  96,  187 
Babes  and  Manicatide,  49 
Babes  and  Sion,  13,  45,  80,  no 
Baillarger,  116 
Balardini,  39,  44 
Ballardino,  15 
Bardin,  160,  161,  162,  163 
Barrett  and  Smith,  199 
Baruch,  201 
Baruino,  13 
Batten,  156 
Belmondo,  49 
Bemis,  27 
Bianchi,  112 
Boltri,  221 
Bonafous,  35 

Brown  and  Carruthers,  20 
Brown  and  Low,  20 
Bucknill  and  Tuke,  no 

Campbell,  56,  131 
Carruthers  and  Brown,  20 
Casal,  14,  19,  34,  88 
Casenave,  177 


91, 
209 


Cattaneo,  220 

Ceconni,  51 

Ceni,  233 

Ceresoli,  221,  222 

Clerici,  112 

Cleveland,  33 

Cole  and  Winthrop,  188 

Crenshaw,  210 

Cuboni,  41 

Cudd,  189 

Curry,  130 

Cutting,  Jr.,  62,  214,  216 

Darwin,  35 
Daves,  139 
De  Giaxa,  50 
Delavan,  142 
D'Oleggio,  14 

Erba,  49 

Ferrati,  49 

Fileti,  43 

Finch,  142 

Fine,  68 

Finzi,  116,  119 

Finzi  and  Vedrani,  117 

Fox,  87,  88,  90,  139,  142 

Frapolli,  12,  14 

Fraser  and  Stanton,  241 

Garrison,  68 

Gaumer,  24 

Goldberger,  62,  73,  74,  76,  i94,  211 

Goldberger  and  Anderson,  243 

Gosio,  49,  217 

Gray,  25,  160 

Gregor,  116,  117,  118 

249 


250 


BIBLIOGRAPHIC  INDEX 


Griesinger,  112 
Griffini,  166 

Haheau,  18 

Harris,  29,  81,  176 

Hausemann,  49 

Hebra,  202 

Heider  and  Paltauf,  41 

Hewett,  30,  132,  139 

Hillman,  68 

Hill  man  and  Schule,  163 

Hinsdale,  202 

Hippocrates,  201 

Hirsch,  20 

Holland,  107 

Howard,  54 

Humboldt,  35 

Hunter,  54 

Jennings,  68 
Jones,  130 

Kekr,  26 
King,  12,  68 
Koch,  42,  187 

L.^NDOrzY,  51 

La\-inder,  18,  21,  44,  46,  48, 154, 180, 

231,  239,  242 
Lavinder  and  Babcock,  227 
LeFrer,  51 
Lombroso,  40,  42,  44,  45,  49,  56,  76, 

78,  no,  117,  180,  184,  185,  188 
Long, 159 
Lorenz,  155 
Lovr  and  Brown,  20 

Majocchi,  40 

Manicatide  and  Babes,  49 

Manning,  23 

Manson,  23,  51 

Marchand,  18 

Marchi,  157,  158 

Mariani,  49 

Marianni  and  Antonini,  188 

Marie,  13,  22,  37,  38,  41,  100,  159 

Mazari,  34 


McFadden,  63,  68,  229 
]SIcXeal,  68 
Merk,  88,  93 
Mesnil,  54 
MizeU,  57 
Mobley,  124 
Mongeri,  112 
Monti  and  Tirelli,  42 
Morselli,  no 
Mott,  156 
Myers,  68 

Neusser,  so,  241 

Niles,  28,  31,  34,  46,  64,  81,  82,  84, 
89,  95,  96,  104,  105,  125,  148,  169, 
192,  198,  199,  205,  207,  208 

OHiIKE,  240 

Pal  and  Weigert,  157,  158 

Paltauf  and  Heider,  41 

Pelizzi,  49 

Pellogio,  49 

Perr>s  142,  143 

Petit.  18 

Piannetta,  116 

Pope,  27 

Procopiu,  84,  93,  114,  127 

Pruner,  20 

Raubitschek.   231,    232,   237,    238, 

239 
Regis,  iS,  113,  116 
Roncoroni,  loi 
Roussel,  51,  79,  83,  93,  III,  213 

Salerio,  109 

Sambon,  17,  20,  54,  55,  244 

Sandwith,  20,  21,  81,  91,  108,  126, 

128,  146,  155,  156,  158,  226 
Santa  Rosa  de  Victerbo,  35 
Scala  and  Alessandrini,  71 
Scheube,  91,  127 
Schule  and  Hillman,  163 
Scipione,  13 
Sherwell,  27 
SUer,  68,  71 


BIBLIOGRAPHIC  INDEX 


251 


Sion  and  Babes,  13,  45,  80,  no 

Sloan,  27 

Smith  and  Barrett,  199 

Stanton  and  Fraser,  241 

Strachan,  21,  23 

Strambio,  14,  78.  79,  93,  96,  no,  113, 

177 
Strobe,  158 

Tanzi,  115,  116,  119,  120 

Taylor,  68 

Thompson,  63,  68,  229 

Thrash,  163,  165,  167 

Tirelli,  49 

Tirelli  and  Monti,  42 

Tonnini,  loi,  102,  103 

Triller,  18,  19 

Tucker,  30 

Tuczek,  117,  154,  156 

Tuke,  109 

Tuke  and  Bucknill,  no 


Tyler,  25 
Typhaldos,  20,  47 

Van  Giesen,  157 
Vcdrani,  116,  119 
Vedrani  and  Finzi,  117 
Verga,  116 

Warnock,  21,  102,  116,  146,  188 
Watson,  87,  88,  89,  90,  127,  139 
Watson  and  Babcock,  29 
Weigert  and  Pal,  157,  158 
Whaley,  125 
Williams,  23 
Winthrop  and  Cole,  188 
Wolff,  65,  139,  141 
WoUenberg,  180 
Wood,  188 
Wright,  68 

Zletarovic,  117 


INDEX 


Acid,  hydrochloric,  absence,  treat- 
ment, 207 
Aerophagia,  95 

Africa,  pellagra  in,  history,  20 
Akoria,  94 
Alcohol,  196 
Alcoholism,  129 
Alpine  scurvy,  11 
Amenorrhea,  130 
Amentia,  115,  120 
Amylophagia,  56 
Anal  irritation,  92 
Anatomy,  morbid,  154 
Andersonville    Prison,  pellagra    in, 
during  Civil  War,  25,  26 

Anesthesia,  102 

Aniline-blue-black   stain   for   spinal 
cord,  examination  in,  157 

Animals,  experiments  on,  231 

Ankylostomiasis,  128 

Anorexia,  94 
treatment,  207 

Anxiety  psychoses,  122 

Aphthous  ulcers,  treatment,  205 

Appendicitis,  131 

Appendix  fasciolea,  88 

Appetite,  loss  of,  94 
treatment,  207 

Arsacetin,  187 

Arsenic,  185,  187,  206 

Artificial  drying  of  corn,  219 

Aspergillus  glaucus,  40 

Asturian  leprosy,  11 
rose,  II 

Atoxyl,  187 

Atropin  for  salivation,  205 

Austria,  pellagra  in,  history,  20 


Babes  and  Sion's  classification,  80 
Bacterium  maidis,  40 

termo,  41 
Bakeries,  rural,  222 
Band,  neck,  88 
Bath,  185,  200 
cold,  202 
hot,  200,  202 
salt,  203 
warm  full,  202 
Beans,  195 
Blood  changes,  160 
occult,  in  stomach,  83 
transfusion  of,  188 
Bones,  brittleness  of,  154.  166 
Brain,  changes  in,  155,  164 
Buba  Tranjilar,  19 
Buccal  infection,  199 

redness,  83 
Bulimia,  94 
Buttermilk,  193 

Cachexia,  79,  154,  iS5 

Cardinal  tongue,  84 

Case-reports,  132 

Catalepsy,  psychical,  no 

Cephalalgia,  104 

Cereals,  195 

Cerebrospinal  fluid,  155 

Chemical  tests  for  spoiled  corn,  217 

Children,  pellagra  in,  66 

Civil  War,  pellagra  in,  25 

Climatic  treatment,  211 

Clinical  reports  and  description  of 

cases,  132 
Cold  bath,  202 
Colon  irrigation,  190 

253 


254 


INDEX 


Commencing  pellagra,  79 
Complications,  128 
Confirmed  peUagra,  79,  177 
Constipation,  95,  207 
Constitutional  treatment,  205 
Continuous  pellagra,  79 
Contractures  in  pellagra,  99 
Corfu,  pellagra  in,  history,  19 
Com.     See  Maize. 
Corn-bread  poison,  81 
Course,  77,  176 
Cretinism,  130 

Definition,  ii 
Deliriimi,  acute,  121 
Dementia,  no,  118 
Derivation  of  word  pellagra,  12 
Desiccation,  artificial,  of  com,  219 
Desiccators,  220 
Diagnosis,  168 

differential,  175 

positive,  172 
Diarrhea,  96,  97 

treatment,  207 
Diet,  185,  192,  194,  229 

Goldberger's,  194 
Digestive  symptoms,  93 
Douche,  rectal,  203 

Scotch,  203 

vaginal,  204 
Drainage  of  gall-bladder,  190 
Drying,  artificial,  of  maize,  219 
Dysentery,  96 
Dyspepsia,  93 
Dysphagia,  98 

Eczema    and    peUagra,    differentia- 
tion, 87 
Eggs,  193,  194 

Egypt,  peUagra  in,  history,  21 
Electric  reactions,  loi 
Emetin,  199,  205 
England,  peUagra  in,  history,  20 
EosinophUia,  161 
Epigastralgia,  93 
Epilepsy,  pellagrous,  no 
Erythema,  86 


Erythema  multiforme  and  pellagra, 
differentiation,  88 
treatment,  209 
Esophagus,  burning  of,  94 
Etiology,  34 

European  war,  pellagra  and,  21 
Eurotium  herbariorum,  40 
Exchanges,  com,  222 
Experiments  on  animals,  231 
Eye  symptoms,  125 

Facial  expression,  106 
Fagopyrismus,  237,  240 
Feces,  odor  of,  96 
Feeding,  forced,  193 
Fever,  125 
Flatulence,  95 
Forced  feeding,  193 
Fowler's  solution,  206 
FragiUtas  ossium,  154,  166 
France,  peUagra  in,  history,  18 

Gait,  102 

GaU-bladder,  drainage,  190 

Gastric  lavage,  204 

symptoms,  82 

ulcer,  95 
Goiter,  130 

Gosio's  test  for  spoiled  com,  217 
Great  Britain,  peUagra  in,  20 

Habits  in  etiology,  66 

Headache,  104 

Heart,  changes  in,  166 

Hemorrhoids,  97 

Heredity  as  predisposing  factor,  64 

Hexamethylenamin,  208 

History,  11,  12 

clinical,  of  cases,  132 

Hook-worm  disease,  128 

Hot  bath,  200,  202 

Hydrochloric    acid,    absence,    treat- 
ment, 207 

Hydromania,  112,  113 

Hydrotherapy,  200 

Hygienic  treatment,  197 


INDEX 


255 


Hyperalgesia,  103 
Hyperthyroidism,  130 

ICHTHYOL,  208 
Idiocy,  115,  120 
Indian  corn.     See  Maize. 
Insanity,  no,  112,  114 

acute  confusional,  120 

maniac-depressive,  123 
Insolation,  vernal,  14 
Insomnia,  106 

treatment,  210 
Intermittent  pellagra,  78 
Intestines,  changes  in,  154,  164 
lodids,  210 
Iron,  185 

arsenite  solution,  206 
Irrigation  of  colon,  190 
Italy,  pellagra  in,  history,  14 
prevention,  214 

Jamaica,  pellagra  in,  history,  21 
Jews,  pellagra  in,  65 

KATATO>fIA,  122 
Kidneys,  changes  in,  166 

Landes,  diseases  of,  11 

Lange's  colloidal  gold  chlorid  test, 

iSS 
Lavage,  gastric,  204 
Lavinder's  theory,  44 
Lead  acetate,  185 
Legtunes,  195 
Leprosy,  Asturian,  11 
Light,  avoidance,  198 
Linolin  as  cause,  57 
Liver,  changes  in,  166 
Lombroso's  theory,  44 

treatment,  184,  185 
Lungs,  changes  in,  156 
Lupus  erythematosus  and  pellagra, 

differentiation,  90 
Lymphocytes,  increase  in,  162,  163 

MAIDISMUS,  II 

Maize,  35 


Maize,  artificial  drying,  219 
distribution  of,  35 
exchanges,  222 
history  of,  35 
photodynamic  substances  in,  237, 

238,  239 
public  storehouses,  221 
spoiled,  as  cause  of  pellagra,  35,44 
Gosio's  test,  217 
micro-organisms  in,  39 
moulds  of ,  41 
parasites  of,  39 
prohibition  of,  216 
red  oil  of,  38 
resinous  substance  of,  39 
substances  yielded  by,  38 
tests  for,  37,  217 
toxic  substance  of,  39 
weevils,  37 
Mai  de  la  Rosa,  12 
Misere,  12 
Rosa,  14 
del  Padrone,  1 2 
Sole,  12 
Maladie  de  la  Teste,  18 
Malaria,  treatment,  207 
Malarial  multiple  neuritis,  21 
Mania,  114,  115 
Maniac-depressive  insanity,  1 23 
Marasmus,  130 

Marchi's  stain  for  spinal  cord,  ex- 
amination in,  157 
Massage,  209 

McFadden-Thompson  Pellagra  Com- 
mission, 68-71 
Mealies,  36 
Meat,  192,  195 
Medicinal  treatment,  204 
Melancholia,  107,  no,  in,  115 
Menorrhagia,  130 
Mental  s3Tnptoms,  105 

treatment,  210 
Mexico,  pellagra  in,  history,  23 
Micro-organisms  in  spoiled  corn,  39 
Milk,  193,  194 
Mizell's  theory,  57 
Morbid  anatomy,  154 


2S6 


INDEX 


Morbus  miseriae,  51 
Mortality,  179 
Moulds  of  spoiled  corn,  41 
Mouth,  care  of,  199 
sore,  84,  85 
treatment,  205 
Multiple  neuritis,  malarial,  21 
Muscular  spasms,  loi 

Neck  band,  88 
Negro,  pellagra  in,  65 
Neosalvarsan,  190 
Nervous  symptoms,  98 
treatment,  208,  209 
system,  changes  in,  154,  158,  159 
Neuralgia,  ovarian,  131 
Neurasthenia,  117 
Neuritis,  malarial  multiple,  21 
Noxe,  237 

Occult  blood  in  stomach,  83 

Occupation  in  etiology,  66 

Ocular  symptoms,  125 

Odor  of  stools,  96 

Oidium  lactis  maidis,  40 

Oil,  olive,  194 
red,  of  spoiled  corn,  38 
semidried  edible,  as  cause,  57 

Olive  oil,  194 

Ovarian  neuralgia,  131 

Pain,  sensibility  to,  102 
Pains,  shooting,  85 

treatment,  208 
Paraffin  Uquid,  208 
Paralysis,  no,  in,  113 
Paralytic  pellagra,  79 
Parasites  of  spoiled  com,  39 
Pathology,  154 
Peas,  19s 
Pellagra,    absence    of    hydrochloric 

acid  in,  treatment,  207 
acute  conf usional  insanity  in,  1 20 

delirium  in,  121 

dementia  in,  118 
aerophagia  in,  95 
akoria  in,  94 


Pellagra,  alcohol  in,  196 

alcoholism  in,  129 

amenorrhea  in,  130 

amentia  in,  115,  120 

anal  irritation  in,  92 

and  eczema,  differentiation,  87 

and  erythema  multiforma,  differ- 
entiation, 88 

and    lupus   erythemata,    differen- 
tiation, 90 

and  potable  waters,  71 

anesthesia  in,  102 

ankylostomiasis  in,  128 

anorexia  in,  94 
treatment,  207 

anxiety  psychoses  in,  122 

aphthous  ulcers  in,  treatment,  205 

appendicitis  in,  131 

appendix  fasciolea  in,  88 

arsacetin  in,  187 

arsenic  in,  185,  187,  206 

atoxyl  in,  187 

avoidance  of  light  in,  198 

Babes  and  Sion's  classification,  80 

baths  in,  185,  200 

beans  in,  195 

blood  changes  in,  160 

brittleness  in  bones  in,  154,  166 

buccal  infection  in,  199 
redness  in,  83 

bulimia  in,  94 

burning  of  esophagus  in,  94 
of  stomach  in,  94 

buttermilk  in,  193 

cachexia  in,  154,  155 

care  of  mouth  in,  199 
of  teeth  in,  199 

cases  of,  clinical  reports,  132 

cephalalgia  in,  104 

cereals  in,  195 

cerebrospinal  fluid  in,  155 

changes  in  blood  in,  160 
in  brain  in,  155,  164 
in  heart  in,  166 
in  intestines  in,  154,  164 
in  kidnej^s  in,  166 
in  liver  in,  166 


INDEX 


257 


Pellagra,  changes  in  lungs  in,  156 
in  nervous  system  in,  154,  158, 

159 

in  skin  in,  166 

in  spinal  cord  in,  156 

in  spleen  in,  166 
classification  of,  78 
climatic  treatment,  211 
clinical  course,  71 
cold  bath  in,  202 
commencing,  79 
Commission,     Thompson-McFad- 

den,  68-71 
complications,  128 
confirmed,  79,  177 
constipation  in,  95 

treatment,  207 
constitutional  treatment,  205 
continuous,  79 
contractures  in,  99 
course  of,  77,  176 
cretinism  in,  130 
cure,  103 
definition,  11 
delirimn  in,  acute,  121 
dementia  in,  no,  118 
derivation  of  word,  12 
diagnosis,  168 

differential,  175 

history  of  case,  171 

positive,  172 
diarrhea  in,  96,  97 

treatment,  207 
diet  in,  185,  192,  194,  229 
digestive  symptoms,  93 
drainage  of  gall-bladder  in,  190 
dysentery  in,  96 
dyspepsia  in,  93 
dysphagia  in,  98 
eggs  in,  193,  194 
electric  reactions  in,  loi 
emetin  in,  199,  205 
eosinophilia  in,  161 
epigastralgia  in,  93 
epilepsy  in,  no 
eruption  on  skin  in,  86 
erythema  in,  86 
17 


Pellagra,    erythema    in,    treatment, 

209 
etiology  of,  34 

habits,  66 

heredity,  64 

linolin,  57 

occupation,  66 

race,  65 

season,  67 

seroidried  edible  oils,  57 

sex,  65 

simulium  theory,  53 

spoiled  maize,  35,  44 

unhygienic  surroundings,  63 
European  war  and,  21 
eye  symptoms,  1 25 
facial  expression  in,  106 
fever  in,  1 25 
first  degree,  79 
flatulence  in,  95 
forced  feeding  in,  193 
Fowler's  solution  in,  206 
fragiUtas  ossiimi  in,  154,  166 
gait  in,  102 
gastric  lavage  in,  204 

sjrmptoms,  82 

ulcer  in,  95 
general  considerations,  11 
goiter  in,  130 
Goldberger's  diet  in,  194 
gynecologic  complications,  130 
habits  in,  etiology  of,  66 
headache  in,  104 
hemorrhoids  in,  98 
heredity  as  predisposing  factor,  64 
hexamethylenamin  in,  208 
history,  n,  12 
hook-worm  disease  in,  128 
hot  bath  in,  200,  202 
hydromania  in,  112,  113 
hydrotherapy  in,  200 
hygienic  treatment,  197 
hyperalgesia  in,  103 
hyperthyroidism  in,  130 
ichthyol  in,  208 
idiocy  in,  115,  120 
in  Africa,  history,  20 


258 


INDEX 


Pellagra    in     .\nder5on\-ille     Prison 

during  Ci\'il  War,  25,  26 
in  Austria,  history,  20 
in  children,  66 
in  Ci\il  War.  25 
in  Corfu,  history-,  19 
in  Eg^-pt,  histor>-,  21 
in  England,  histor,-,  20 
in  France,  histor>',  18 
in  Great  Britain,  20 
in  Italy,  history,  14 

prevention,  214 
in  Jamaica,  history,  21 
in  Jews,  65 
in  Mexico,  historj-,  23 
in  negro,  65 

in  Roumania,  history,  19 
in  Southern  States,  27 
in  Spain,  histor}%  13,  18 
in  United  States,  25 
in  Yucatan,  history,  23 
increase  in  ljTnphoc>i;es  in,  162, 

163 
insanity  in,  no,  112,  114 
insomnia  in,  106 

treatment,  210 
intermittent,  78 
iodids  in,  210 
iron  in,  185 

arsenite  solution  in,  206 
irrigation  of  colon  in,  190 
katatonia  in,  122 
Lange"s  colloidal  gold  chlorid  test 

in.  155 
La\-inder's  theon,-,  44 
lead  acetate  ia.  185 
legumes  in,  195 
linolin  as  cause,  57 
Lombroso's  theory,  44 

treatment,  184,  185 
loss  of  appetite  in,  94 

treatment,  207 
IjTnphocj-tes  in,  increase   in,    162, 

163 
malaria   complicating,   treatment, 

207 
mania  in,  114,  115 


Pellagra,  maniac-depressive  insanity 

in,  123 
marasmus  in,  130 
massage  in,  209 
meat  in,  192,  195 
medicinal  treatment,  204 
melancholia  in,  107,  no,  in,  115 
menorrhagia  in,  130 
mental  s>-mptoms,  105 

treatment,  210 
milk  in,  193,  194 
^Mizell's  theory,  57 
morbid  anatomy,  154 
mortalit}',  179 
mouth  in,  care,  199 
muscular  spasms  in,  loi 
neck  band  in,  88 
neosalvarsan  in,  190 
ner\-ous  ssTnptoms,  98 

treatment,  208,  209 
neurasthenia  in,  117 
occult  blood  in  stomach  in,  83 
occupation  in,  etiology  of,  66 
ocular  s}Tnptoms,  125 
odor  of  feces  in,  96 
olive  oil  in.  194 
ovarian  neuralgia  in,  131 
pains  in,  85 

treatment,  208 
paraffin  liquid  in,  208 
paralysis  in,  79,  no,  in,  113 
patholog}-,  154 
peas  in,  105 

pigmentarj-  degenerations  in,  167 
potable  waters  and.  71 
potassium  iodid  in,  206 
pregnancy  in,  130 
prodromal  period,  81 
prognosis,  179 
pronunciation,  12 
prophylaxis,  213 

ad\-ice  and  rules,  227 
pruritus  in.  105 
psychic  sjTnptoms,  105 

treatment,  210 
psychical  catalepsy  in,  no 
pyorrhea  alveolaris  in,  129,  199 


INDEX 


259 


Pellagra,  race  in  etiology  of,  65 
Raubitschek's  experiments,  231 
rectal  douche  in,  203 
reflexes  in,  loi 
remittent,  79 
rest  in,  197 
Rontgen  ray  in,  198 
Roussel's  classification,  79 
saliva  in,  84 

salivation  in,  atropin  for,  205 
salt  bath  in,  203 
salvarsan  in,  190,  210 
Sambon's  theory,  52,  244 
scarlet-red  ointment  in,  209 
Scotch  douche  in,  203 
season  in,  etiology  of,  67 
second  degree,  79 
semidried  edible  oils  as  cause,  57 
sensibility  to  pain  in,  102 

to  touch  in,  102 
serum  treatment,  188 
sex  in  etiology  of,  65 
sexual  desire  in,  104 
shooting  pains  in,  85 

treatment,  208 
simulimn  theory,  53 
sine  pellagra,  93,  175 
sitophobia  in,  94 
skin  reflexes  in,  loi 

symptoms,  86 
smell  in,  104 
soamin  in,  187,  188 
sodium  acetyl  arsanilate  in,  187 

arsanilate  in,  187 

cacodylate  in,  206 

chlorid  in,  185 
sore  mouth  in,  84,  85 
treatment,  205 

tongue  in,  treatment,  205 
spoiled  com  as  cause,  35,  44 
Strambio's  classification,  78 
supra-acute,  no 
surgical  treatment,  189 
symptoms  of,  77 

digestive,  93 

gastric,  82 

mental,  105 


Pellagra,  symptoms  of,  nervous,  98 

ocular,  125 

psychic,  105 

skin,  86 
synonyms,  11 
sjTphilis  in,  130 
tannigen  in,  207 
taste  in,  105 
teeth  in,  care,  199 
temperature  in,  125 
thermal  phenomena,  125 
third  degree,  79 
thyroid  disease  in,  130 
tongue  in,  83,  84,  85 
transfusion  of  blood  in,  188 
treatment,  184 

climatic,  211 

constitutional,  205 

dietetic,  191 

hydrotherapeutic,  200 

hygienic,  197 

medicinal,  204 

prophylactic,  213 

surgical,  189 
tremors  in,  99 

tuberculosis  complicating,  161 
typhoid,  no,  iii,  126 

prognosis,  182 
unhygienic  surroundings  as  cause, 

63 
vaginal  douche  in,  204 

irritation  in,  92 
vegetables  in,  195 
vomiting  in,  94 
vulvar  irritation  in,  91,  92 
warm  full  bath  in,  202 
Wassermann  test  in,  155 
water  drinking  in,  204 
wet  cases,  92 
x-ray  in,  198 
Zeist  theory,  34 
Pellagrocein,  39 
Pellagrous  cachexia,  79 

tetanus,  no 
Pellagrozeina,  40 
Pellarella,  12,  14 
Penicillium,  40 


26o 


INDEX 


Penicillium  glaucum,  40 
Photodynamic  substances  in  maize, 

237,  238,  239 
Pigmentary  degenerations,  167 
Poison,  corn-bread,  81 
Potable  waters,  pellagra  and,  71 
Potassium  iodid,  206 
Pregnancy,  130 
Prison,    Anderson\'ille,   pellagra   in, 

during  Civil  War,  25,  26 
pellagra  in,  during  Civil  War,  25 
Prodromal  period,  81 
Prognosis,  179 
Pronimciation,  12 
Pruritus,  105 
Pseudopellagra,  51 
Psychic  symptoms,  105 

treatment,  210 
Psychical  catalepsy,  no 
Psychoneurosis  Maidica,  1 1 
Psychoses,  anxiety,  122 
Public  storehouses  for  com,  221 
Pyorrhea  alveolaris,  129,  199 

Race  in  etiology,  65 

Raubitschek's  experiments,  231 

Rectal  douche,  203 

Red  oU  of  spoiled  com,  38 

Redness,  buccal,  83 

Reflexes,  loi 

Remittent  pellagra,  79 

Resinous  substance  of  spoUed  com, 

39 
Rest,  197 
Rontgen  ray,  198 
Rose,  Asturian,  11 
Roumania,  pellagra  in,  history,  19 
Roussel's  classification,  80 
Rub,  salt,  203 
Rural  bakeries,  222 

Salwa,  84 

Salivation,  atropin  for,  205 
Salt  bath,  203 
Salvarsan,  190,  210 
Sambon's  theory,  52,  244 
Scarlet-red  ointment,  209 


Scorbutus  alpinus,  14 
Scotch  douche,  203 
Scurvy,  Alpine,  11 
Season  in  etiology,  67 
Serum  treatment,  188 
Sex  in  etiology,  65 
Sexual  desire,  104 
Shooting  pains,  85 
treatment,  208 
Silver  nitrate  in  sore  mouth,  205 
Simulimn  omatum,  54 

pecarum,  54 

pubescans,  54 

reptans,  53,  54,  244 

theory,  53 

venistmn,  54 
Sitophobia,  94 
Skin,  changes  in,  166 

reflexes,  loi 

symptoms,  86 
Smell,  104 
Soamin,  187,  188 
Sodium  arsanilate,  187 

cacodylate,  206 

chlorid,  185 
Sore  mouth,  84,  85 
treatment,  205 

tongue,  treatment,  205 
Southern  States,  pellagra  in,  27 
Spain,  pellagra  in,  history,  13,  18 
Spasms,  muscular,  in  pellagra,  loi 
Spinal  cord,  changes  in,  156 
Spleen,  changes  in, 166 
Sporisorium  maidis,  39 
Sporothricum  maidis,  40 
Stain,  analin-blue-black,  for  spinal 
cord,  examination  in,  157 

Marchi's,  for  spinal  cord,  examina- 
tion in,  157 

Van  Giesen's,  for  spinal  cord,  ex- 
amination in,  157 

Weigert-Pal,  for  spinal  cord,  ex- 
amination in,  157 
Stomach,  burning  of,  94 

lavage,  204 
Stools,  odor  of,  96 
Storehouses,  public,  for  com,  221 


INDEX 


261 


Strachan's  disease,  22 
Strambio's  classification,  78 
Stuporous  dementia,  118 
Sunlight,  avoidance,  198 
Sjonptoms,  77 
Synonyms,  11 
Syphilis,  130 

Taishnigen,  207 

Taste,  105 

Teeth,  care  of,  199 

Temperature,  125 

Test,  Wassermann,  155 

Tests  for  spoiled  com,  37,  217 

Tetanus,  no 

Thermal  phenomena,  125 

Thompson-McFadden  Pellagra  Com- 
mission, 68-71 

Thyroid  disease,  130 

Tongue,  83,  84,  85 
cardinal,  84 
sore,  treatment,  205 

Touch,  sensibility  to,  102 

Transfusion  of  blood,  188 

Treatment,  184 

Tremors,  99 

Tuberculosis,  161 

Typhoid  pellagra,  no,  11 1,  126 
prognosis,  182 

Typhus  pellagrosus,  127 


Ulcer,  aphthous,  treatment,  205 

gastric,  95 
United  States,  pellagra  in,  25 

Vaginal  douche,  204 

irritation,  92 
Van  Giesen's  stain  for  spinal  cord, 

examination  in,  157 
Vegetables,  195 
Vernal  insolation,  14 
Vomiting,  94 
Vxilvar  irritation,  91,  92 

War,  Civil,  pellagra  in,  25 
European,  pellagra  and,  21 

Warm  full  bath,  202 

Wassermann  test,  155 

Water,  drinking-,  204 

Waters,  potable,  pellagra  and,  71 

Weigert-Pal   stain  for   spinal  cord, 
examination  in,  157 

Wet  cases,  92 

X-RAY,  198 

Yucatan,  pellagra  in,  history,  23 
Zeist  theory  of  pellagra,  34 


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"  Dr.  DeLee's  Obstetrics  deserves  the  greatest  recognition.  The  text  and  the  913  very  beau- 
tiful illustrations  prove  that  it  is  written  by  an  obstetrician  of  ripe  experience  and  of  exceptional 
teaching  ability.     It  must  be  ranked  with  the  best  works  of  our  literature." 

Dr.  George  L.  Brodhead,  New  York  Post- Graduate  Medical  School 

"  The  name  of  the  author  is  in  itself  a  sufficient  guarantee  of  the  merit  of  the  book,  and  1 
congratulate  him,  as  well  as  you,  on  the  superb  work  just  published." 


G  YNECOL OG  Y  AND  OBSTETRICS. 


Norris* 
Gonorrhea  in  Women 

Gonorrhea  in  Women.  By  Charles  C.  Norris,  M.  D.,  Instructor 
in  Gynecology,  University  of  Pennsylvania.  With  an  Introduction  by 
John  G.  Clark,  M.  D.,  Professor  of  Gynecology,  University  of  Penn- 
sylvania.    Large  octavo  of  520  pages,  illustrated.  Cloth,  ^^6.00  net. 

A   CLASSIC 

Dr.  Norris  here  presents  a  work  that  is  destined  to  take  high  place  among 
pubhcations  on  this  subject.  He  has  done  his  work  thoroughly.  He  has  searched 
the  important  literature  very  carefully,  over  2300  references  being  utihzed.  This, 
coupled  with  Dr.  Norris'  large  experience,  gives  his  book  the  stamp  of  authority. 
The  chapter  on  serum  and  vaccine  therapy  and  organotherapy  is  particularly 
valuable  because  it  expresses  the  newest  advances.  Every  phase  of  the  subject 
is  considered  :  History,  bacteriology,  pathology,  sociology,  prophylaxis,  treatment, 
gonorrhea  during  pregnancy,  parturition  and  puerperium,  and  all  other  phases. 

Pennsylvania  Medical  Journal 

"  Dr.  Norris  has  succeeded  in  presenting  most  comprehensively  the  present  knowledge  of 
gonorrhea  in  women  in  its  many  phases.  The  present  status  of  serum  and  vaccine  therapy  is 
given  in  detail." 

American  Text-Book  qf  Gynecology 

Second    Revised    Edition 
American  Text=Book  of  Gynecology.     Edited   by  J.    M.    Baldy, 
M.  D.     Imperial  octavo  of  718  pages,  with  341   text-illustrations  and 
38  plates.     Cloth,  ;^6.oo  net. 

American  Text-Book  qf  Obstetrics 

Second    Revised    Edition 
The  American  Text=Book  of  Obstetrics.     In  two  volumes.    Edited 
by  Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dickinson,  M.  D. 
Two  octavos  of  about  600  pages  each  ;  nearly  900  illustrations,  includ- 
ing 49  colored  and  half-tone  plates.      Per  volume  :  Cloth,  ;^3.50  net 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  practi- 
tioner, we  commend  it  because  we  believe  there  is  no  better." — American  Journal  of  thb 
Medical  Sciences. 


SAUNDERS'   BOOKS   ON 


Ashton's 
Practice  of  Gynecology 


The  Practice  of  Gynecology.  By  W.  Easterly  Ashton,  M.  D., 
LL.D.,  Professor  of  Gynecology  in  the  Medico-Chirurgical  College, 
Philadelphia.  Handsome  octavo  volume  of  i  lOO  pages,  containing  1058 
original  line  drawings.     Cloth,  $6.^0  net;  Half  Morocco,  ^8.00  net. 

NEW  (5th)  EDITION 

The  continued  success  of  Dr.  Ashton' s  work  is  not  surprising  to  any  one 
knowing  the  book.  The  author  takes  up  each  procedure  necessary  to  gynecologic 
step  by  step,  the  student  bein^?-  led  from  one  step  to  another,  just  as  in  studying 
any  non-medical  subject,  the  minutest  detail  being  explained  in  language  that 
cannot  fail  to  be  understood  even  at  first  reading.  Nothing  is  left  to  be  taken  for 
granted,  the  author  not  only  telling  his  readers  in  every  instance  what  should  be 
done,  but  also  precisely  how  to  do  it.  A  distinctly  original  feature  of  the  book  is 
the  illustrations,  numbering  1058  line  drawings  made  especially  under  the  author's 
personal  supervision  from  actual  apparatus,  Hving  models,  and  dissections  on  the 
cadaver. 

From  its  first  appearance  Dr.  Ashton' s  book  set  a  standard  in  practical 
medical  books  ;  that  he  has  produced  a  work  of  unusual  value  to  the  medical 
practitioner  is  shown  by  the  demand  for  new  editions.  Indeed,  the  book  is  a 
rich  store-house  of  practical  information,  presented  in  such  a  way  that  the  work 
cannot  fail  to  be  of  daily  service  to  the  practitioner. 

Howard  A.  Kelly,  M.  D. 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University. 

"  It  is  different  from  anything  that  has  as  yet  appeared.  The  illustrations  are  particularly 
clear  and  satisfactory.  One  specially  good  feature  is  the  pains  with  which  you  describt  sc 
many  details  so  often  left  to  the  imagination." 

Charles  B.  Penrose,  M.  D. 

Fortnerly  Professor  of  Gynecology  in  the  University  of  Pennsylvania 

"  I  know  of  no  book  that  goes  zo  thoroughly  and  satisfactorily  into  all  the  details  of  every 
thing  connected  with  the  subject.     In  this  respect  your  book  differs  from  the  others." 

George  M.  Edebohls,  M.  D. 

Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical  School 
"A  text-book  most  admirably  adapted  to  teach  gynecology  to  those  who  must  get  ihei* 
icnowledge,  even  to  the  minutest  and  most  elementary  details,  from  books." 


GYNECOLOGY  AND    OBSTETRICS 


Bandler*s 
Medical    Gynecology 


Medical  Gynecology.  By  S.  Wyllis  Bandler,  M.  D.,  Adjunct 
Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical 
School  and  Hospital.  Octavo  of  790  pages,  with  150  original  illus- 
trations.    Cloth,  $5.00  net ;  Half  Morocco,  ^6.50  net 

NEW  (3d)   EDITION-60  PAGES  ON  INTERNAL  SECRETIONS 

This  new  work  by  Dr.  Bandler  is  just  the  book  that  the  physician  engaged  in 
general  practice  has  long  needed.  It  is  truly  the  practitioner' s  gynecology— ^\^.nri&d. 
for  him,  written  for  him,  and  illustrated  for  him.  There  are  many  gynecologic 
conditions  that  do  not  call  for  operative  treatment ;  yet,  because  of  lack  of  that 
special  knowledge  required  for  their  diagnosis  and  treatment,  the  general  practi- 
tioner has  been  unable  to  treat  them  intelligently.  This  work  not  only  deals 
with  those  conditions  amenable  to  non-operative  treatment,  but  it  also  tells  how  to 
recognize  those  diseases  demanding  operative  treatment. 

Americsoi  Journal  of  Obstetrics 

"  He  has  shown  good  judgment  in  the  selection  of  his  data.  He  has  placed  most  emphasis 
on  diagnostic  and  therapeutic  aspects.  He  has  presented  his  facts  in  a  manner  to  be  readily 
grasped  by  the  general  practitioner." 


B&ndler's  Vaginal  Celiotomy 

Vaginal  Celiotomy.  By  S.  Wyllis  Bandler,  M.  D.,  New  York 
Post-Graduate  Medical  School  and  Hospital.  Octavo  of  450  pages,  with 
148  original  illustrations.     Cloth,  $5.00  net;  Half  Morocco,  $6.50  net. 

SUPERB  ILLUSTRATIONS 

The  vaginal  route,  because  oi  its  simplicity,  ease  of  execution,  absence  ot 
shock,  more  certain  results,  and  the  opportunity  for  conservative  measures,  con- 
stitutes a  field  which  should  appeal  to  all  surgeons,  gynecologists,  and  obstetricians. 
Posterior  vaginal  cehotomy  is  of  great  importance  in  the  removal  of  small  tubal 
and  ovarian  tumors  and  cysts,  and  is  an  Important  step  in  the  performance  of 
vaginal  myomectomy,  hysterectomy,  and  hysteromyomectomy.  Anterior  vaginal 
celiotomy  with  thorough  separation  of  the  bladder  is  the  only  certain  method 
of  correcting  cystocele. 

The  Lancet,  London 

"  Dr.  Bandler  has  done  good  service  in  writing  this  book,  which  gives  a  very  clear  descrip- 
tion of  all  the  operations  which  may  be  undertaken  through  the  vagina.  He  makes  out  ?■ 
strong  case  for  these  operations." 


SAUNDERS'    BOOKS    ON 


Kelly  and   Noble's 

Gynecology 

and  Abdominal  Surgery 

Gynecology  and  Abdominal  Surgery.  Edited  by  Howard  A. 
Kelly,  M.  D.,  Professor  of  Gynecology  in  Johns  Hopkins  University  ; 
and  Charles  P.  Noble,  M.  D.,  formerly  Clinical  Professor  of  Gyne- 
cology in  the  Woman's  Medical  College,  Philadelphia.  Two  imperial 
octavo  volumes  of  950  pages  each,  containing  880  illustrations,  some  in 
colors.     Per  volume:  Cloth,  $8.00  net ;  Half  Morocco,  ^9.50  net. 

TRANSLATED  INTO  SPANISH 
WITH  880  ILLUSTRATIONS   BY  HERMANN  BECKER  AND   MAX   BRODEL 

In  view  of  the  intimate  association  of  gynecology  with  abdominal  surgery  the 
editors  have  combined  these  two  important  subjects  in  one  work.  For  this  reason 
the  work  will  be  doubly  valuable,  for  not  only  the  gynecologist  and  general  prac- 
titioner will  find  it  an  exhaustive  treatise,  but  the  surgeon  also  will  find  here  the 
latest  technic  of  the  various  abdominal  operations.  It  possesses  a  number  ot 
valuable  features  not  to  be  found  in  any  other  publication  covering  the  same  fields. 
It  contains  a  chapter  upon  the  bacteriology  and  one  upon  the  pathology  of  gyne- 
cology, dealing  fully  with  the  scientific  basis  of  gynecology.  In  no  other  work 
can  this  information,  prepared  by  specialists,  be  found  as  separate  chapters. 
There  is  a  large  chapter  devoted  entirely  to  medical  gynecology  written  especially 
for  the  physician  engaged  in  general  practice.  Heretofore  the  general  practitioner 
was  compelled  to  search  through  an  entire  work  in  order  to  obtain  the  information 
desired.  Abdotninal  surgery  proper,  as  distinct  from  gynecology,  is  fully  treated, 
embracing  operations  upon  the  stomach,  upon  the  intestines,  upon  the  liver  and 
bile-ducts,  upon  the  pancreas  and  spleen,  upon  the  kidneys,  ureter,  bladder,  and 
the  peritoneum.  The  illustrations  are  truly  magnificent,  being  the  work  of  Mr. 
Herma7tn  Becker  and  Mr.  Max  Brodel. 

Americaul  Journal  of  the  Medical  Sciences 

"  It  is  needless  to  say  that  the  work  has  been  thoroughly  done :  the  names  of  the  authors 
and  editors  would  guarantee  this ;  but  much  may  be  said  in  praise  of  the  method  of  presen- 
tation, and  attention  may  be  called  to  the  inclusion  of  matter  uot  to  be  found  elsewhere." 


G  VNECOL OGV  A ND   OBSTE TRIGS 


Webster's 
Text-Book  qf  Obstetrics 

A  Text-Book  of  Obstetrics.  By  J.  Clarence  Webster,  M.  D. 
(Edin.),  F.  R.  C.  p.  E.,  Professor  of  Obstetrics  and  Gynecology  in  Rush 
Medical  College,  in  affiliation  with  the  University  of  Chicago.  Octavo 
volume  of  J^J  pages,  illustrated.  Cloth,  ^5.00  net;  Half  Morocco, 
$6.^0  net. 

BEAUTIFULLY     ILLUSTRATED 

In  this  work  the  anatomic  changes  accompanying  pregnancy,  labor,  and  the 
puerperium  are  described  more  fully  and  lucidly  than  in  any  other  text-book  on 
the  subject.  The  exposition  of  these  sections  is  based  mainly  upon  studies  of 
frozen  specimens.  Unusual  consideration  is  given  to  embryologic  and  physiologic 
data  of  importance  in  their  relation  to  obstetrics. 

Buffalo  Medical  Journal 

"  As  a  practical  text-book  on  obstetrics  for  both  student  and  practitioner,  there  is  left  very 
little  to  be  desired,  it  being  as  near  perfection  as  any  compact  work  that  has  been  published." 


Webster*s 
Diseases  of  Women 

A  Text=Book  of  Diseases  of  Women.  By  J.  Clarence  Webster, 
M.  D.  (Edin.),  F.  R.  C.  P.  E.,  Professor  of  Gynecology  and  Obstetrics 
in  Rush  Medical  College.  Octavo  of  712  pages,  with  372  text-illustra- 
tions and  10  colored  plates.     Cloth,  ^7.00  net ;  Half  Morocco,  $8.50  net. 

Dr.  Webster  has  written  this  work  especially  for  the  general  practitioner,  dis- 
cussing the  cHnical  features  of  the  subject  in  their  widest  relations  to  general 
practice  rather  than  from  the  standpoint  of  specialism.  The  magnificent  illus- 
trations, three  hundred  and  seventy-two  in  number,  are  nearly  all  original. 

Howard  A.  Kelly.  M,  D. 

Professor  of  Gynecologic  Surgery,  Johns  Hcfpkins  University. 

"It  is  undoubtedly  one  of  the  best  works  which  has  been  put  on  the  market  within  recent 
years,  showing  from  start  to  finish  Dr.  Webster's  well-known  thoroughness.  The  illustrations 
are  also  of  the  highest  order." 


SAUNDERS'   BOOKS   ON 


Hirst's 
Text-Book  of  Obstetrics 

The  New  (7th)  Edition 


A  Text=Book  ot  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome 
octavo  of  1013  pages,  with  895  illustrations,  53  of  them  in  colors. 
Cloth,  ^5.00  net ;  Half  Morocco,  $6.50  net. 

INCLUDING  RELATED  GYNECOLOGIC  OPERATIONS 

Immediately  on  its  publication  th^  work  took  its  place  as  the  leading  text-book 
on  the  subject.  Both  in  this  country  and  in  England  it  is  recognized  as  the  most 
satisfactorily  written  and  clearly  illustrated  work  on  obstetrics  in  the  language. 
The  illustrations  form  one  of  the  features  of  the  book.  They  are  numerous  and 
the  most  of  them  are  original.  In  this  edition  the  book  has  been  thoroughly  revised. 
Recognizing  the  inseparable  relation  between  obstetrics  and  certain  gynecologic 
conditions,  the  author  has  included  all  the  gynecologic  operations  for  complica- 
tions and  consequences  of  childbirth,  together  with  a  brief  account  of  the  diagnosis 
and  treatment  of  all  the  pathologic  phenomena  peculiar  to  women. 


OPINIONS  OF  THE  MEDICAL  PRESS 


British  Medical  JoumeJ 

"  The  popularity  of  American  text-books  in  this  country  is  one  of  the  features  of  recent 
years.  The  popularity  is  probably  chiefly  due  to  the  great  superiority  of  their  illustrations 
over  those  of  the  English  text-books.  The  illustrations  in  Dr.  Hirst's  volume  are  far  more 
numerous  and  far  better  executed,  and  therefore  more  instructive,  than  those  commonly 
found  in  the  works  of  writers  on  obstetrics  in  our  own  country." 

Bulletin  of  Johns  Hopkins  Hospital 

"The  work  is  an  admirable  one  in  every  sense  of  the  word,  concisely  but  comprehensively 
written." 

The  Medical  Record,  New  York 

"  The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the  first 
time.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never  necessary 
to  re-read  a  sentence  in  order  to  grasp  the  meaning.  As  a  true  model  of  what  a  modern  text- 
book on  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's  book  's  v/ithout  a 
rival," 


DISEASES   OF    WOMEN. 


HirstV 
Diseases  of  Women 


A  Text=Book  of  Diseases  of  Women.  By  Barton  Cooke  Hirst, 
M.  D.,  Professor  of  Obstetrics,  University  of  Pennsylvania ;  Gynecolo- 
gist to  the  Howard,  the  Orthopedic,  and  the  Philadelphia  Hospitals. 
Octavo  of  745  pages,  with  701   original  illustrations,  many  in  colors. 

Cloth,  $5.00  net;  Half  Morocco,  ^6.50  net. 

THE    NEW   (2d)    EDITION 
WITH    701    ORIGINAL    ILLUSTRATIONS 

The  new  edition  of  this  work  has  just  been  issued  after  a  careful  revision. 
As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering  diseases 
of  women,  particular  attention  has  been  devoted  to  these  divisions.  To  this  end, 
also,  the  work  has  been  magnificently  illuminated  with  701  illustrations,  for  the 
most  part  original  photographs  and  water-colors  of  actual  clinical  cases  accumu- 
lated during  the  past  fifteen  years.  The  palliative  treatment,  as  well  as  the 
radical  operative,  is  fully  described,  enabling  the  general  practitioner  to  treat 
many  of  his  own  patients  ^>  ithout  referring  them  to  a  specialist.  An  entire  sec- 
tion is  devoted  to  ?.  full  description  of  all  modern  gynecologic  operations,  illumi- 
nated and  elucidated  by  numerous  photographs.  The  author's  extensive  ex- 
perience renders  i;his  work  of  unusual  value. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  Record,  New  York 

"  Its  merits  can  be  appreciated  only  by  a  careful  perusal.  .  .  .  Nearly  one  hundred  pages 
are  devoted  to  technic,  this  chapter  being  in  some  respects  superior  to  the  descriptions  in 
many  other  text-  boks." 

Boston  Medical  and  Surgical  Journal 

"The  author  has  given  special  attention  to  diagnosis  and  treatment  throughout  the  book, 
and  has  produced  a  practical  treatise  which  should  be  of  the  greatest  value  to  the  student,  the 
general  practitioner,  and  the  specialist." 

Medical  News,  New  York 

"  Office  treatment  is  given  a  due  amount  of  consideration,  so  that  the  work  will  be  as 
useful  to  the  non-operator  as  to  the  specialist." 


SAUNDERS'    BOOKS   ON 


GET  A  •  THE  NEW 

THE  BEST  /\  lU  C  r  1  C  Sill  STANDARD 

Illustrated   Dictionary 

New  (7thj  Edition— 5000  Sold  in  Two  Months 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches;  with  over  lOO  new  and  elaborate  tables  and  many  handsome 
illustrations.  By  W.  A.  NeWxMAN  Borland,  M.D.,  Editor  of  "The 
American  Pocket  Medical  Dictionary."  Large  octavo,  1107  pages, 
bound  in  full  flexible  leather.  Price,  $^.$0  net;  with  thumb  index, 
$5.00  net. 

IT  DEFINES  ALL  THE  NEW  WORDS— MANY  NEW  FEATURES 

The  American  Illustrated  :\Iedical  Dictionary  defines  hundreds  of  the  newest 
terms  not  defined  in  any  other  dictionary — bar  none.  These  new  terms  are  live, 
active  words,  taken  right  from  modern  medical  literature. 

It  gives  the  capitalization  and  pronunciation  of  all  words.  It  makes  a  feature 
of  the  derivation  or  etymology  of  the  words.  In  some  dictionaries  the  etymology 
occupies  only  a  secondary  place,  in  many  cases  no  derivation  being  given  at  all. 

In  the  '  'American  Illustrated ' '  practically  every  word  is  given  its  derivation. 

Every  word  has  a  separate  paragraph,  thus  making  it  easy  to  find  a  word 
quickly. 

The  tables  of  arteries,  muscles,  nerves,  veins,  etc.,  are  of  the  greatest  help 
in  assembling  anatomic  facts.  In  them  are  classified  for  quick  study  all  the 
necessary  information  about  the  various  structures. 

Every  word  is  given  its  definition — a  definition  that  defines  in  the  fewest  pos- 
sible words.  In  some  dictionaries  hundreds  of  words  are  not  defined  at  all,  refer- 
ring the  reader  to  some  other  source  for  the  information  he  wants  at  once. 

Howeird  A.  Kelly,  M.  Yi.,  Johns  Hopkins  University,  Baltimore 

"The  American  Illustrated  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such 
convenient  size.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.  D..  LL.D.,  F.R.C.S.  (Hon.).  Harvard  Medical  School 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.  It  is  ver}-  complete  and  of 
convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


GYNECOLOGY  AND    OBSTETRICS 


Penrose's 
Diseases  of  Women 

Sixth    Revised    Edition 


A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose, 
M,  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of 
Pennsylvania ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Oc- 
tavo volume  of  550  pages,  with  225  fine  original  illustrations.     Cloth, 

tl-n  net. 

ILLUSTRATED 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modern  and  progressive 
technique  is  adopted  and  made  clear  by  excellent  illustrations. 

Howard  A.  Kelly.  M.D.. 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University,  Baltimore. 
"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women '  received.     I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." 


Davis*  Operative  Obstetrics 

Operative  Obstetrics.  By  Edward  P.  Davis,  M.D.,  Professor  of 
Obstetrics  at  Jefferson  Medical  College,  Philadelphia.  Octavo  of  483 
pages,  with  264  illustrations.     Cloth,  $5.50  net;  Half  Morocco,  $7.00  net. 

INCLUDING  SURGERY  OF  NEWBORN 

Dr.  Davis'  new  work  is  a  most  practical  one,  and  no  expense  has  been  spared 
to  make  it  the  handsomest  work  on  the  subject  as  well.  Every  step  in  every 
operation  is  described  minutely,  and  the  technic  shown  by  beautiful  new  illustra- 
tions.    Dr.  Davis'  name  is  sufficient  guarantee  for  something  above  the  mediocre. 


'2  SAUNDERS'    BOOKS   ON 


Dorland*s 
Modern   Obstetrics 


Modern  Obstetrics :  General  and  Operative.  By  W.  A.  Newman 
Borland,  A.  M.,  M.  D.,  formerly  Professor  of  Obstetrics  at  Loyola 
University,  Chicago,  Illinois.  Handsome  octavo  volume  of  797  pages, 
with  201  illustrations.     Cloth,  $4.00  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  verj^  greatly  enlarged. 
Among  the  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 
infant  mortality,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 
sented in  a  most  instructive  and  acceptable  form. 

Journal  of  the  Americem  Medical  Association 

"  This  work  deserves  commendation,  and  that  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis*  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.    By  Edward  P.  Davis,  A.  M., 

M.  D.,  Professor  of  Obstetrics  in  the  Jefferson  Medical  College  and 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia 
Hospital.      i2mo  of  480  pages,  illustrated.     Buckram,  $1."/^  net. 

NEW  (4th)  EDITION 

Obstetric  nursing  demands  some  knowledge  of  natural  pregnancy,  and  gyne- 
cologic nursing,  really  a  branch  of  surgical  nursing,  requires  special  instruction 
and  training.  This  volume  presents  this  information  in  the  most  convenient 
form.  This  third  edition  has  been  very  carefully  revised  throughout,  bringing  the 
subject  down  to  date. 

The  Lancet,  London 

"  Not  onlv  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTETRICS.  1 3 

Kelly  anb  Cullen*s 
Myomata   of  the  Uterus 


Myomata  of  the  Uterus.  By  Howard  A.  Kelly,  M.  D.,  Professor 
of  Gynecologic  Surgery  at  Johns  Hopkins  University;  and  Thomas  S. 
CuLLEN,  M.  B.,  Associate  in  Gynecology  at  Johns  Hopkins  University. 
Large  octavo  of  about  700  pages,  with  388  original  illustrations,  by 
August  Horn  and  Hermann  Becker.  Cloth,  $^.^0  net ;  Half  Morocco, 
;^9.oo  net. 

ILLUSTRATED     BY     AUGUST     HORN     AND     HERMANN     BECKER 

This  monumental  work,  the  fruit  of  over  ten  years  of  untiring  labors,  will 
remain  for  many  years  the  last  word  upon  the  subject.  Written  by  those  men 
who  have  brought,  step  by  step,  the  operative  treatment  of  uterine  myoma  to 
such  perfection  that  the  mortality  is  now  less  than  one  per  cent.,  it  stands  out  as 
the  record  of  greatest  achievement  of  recent  times. 

Surgery,  Gynecology,  and  Obstetrics 

"  It  must  be  considered  as  the  most  comprehensive  work  of  the  kind  yet  published.  It 
will  always  be  a  mine  of  wealth  to  future  students." 


Cullen's  Adenomyoma  of  the  Uterus 

Adenomyoma  of  the  Uterus.  By  Thomas  S.  Cullen,  M.  B.  Octavo  of  275 
pages,  with  original  illustrations  by  Hermann  Becker  and  August  Horn.  Cloth, 
^5.00  net;   Half  Morocco,  ^6.50  net. 

"A  good  example  of  how  such  a  monograph  should  be  written.  It  is  an  excellent 
work,  worthy  of  the  high  reputation  of  the  author  and  of  the  school  from  which  it 
emanates." — The  Lancet,  London. 

Cullen's  Cancer  of  the  Uterus 

Cancer  of  the  Uterus.  By  Thomas  S.  Cullen,  M.  B.  Large  octavo  of  693 
pages,  with  over  300  colored  and  half-tone  text-cuts  and  eleven  lithographs.  Cloth, 
^7.50  net ;  Half  Morocco,  ^8.50  net. 

"  Dr.  Cullen's  book  is  the  standard  work  on  the  greatest  problem  which  faces  the 
surgical  world  to-day.  Any  one  who  desires  to  attack  this  great  problem  must  have 
this  book." — Howard  A.  Kelly.  M.  D.,  Johns  Hopkins  University. 


14  SAUNDERS'    BOOKS   ON 


Schaffer  and  Edgar's  Labor  and  Operative  Obstetrics 

Atlas  and    Epitome  of    Labor    and    Operative    Obstetrics.      By   Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  -svith  additions,  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery-,  Cornell  University 
Medical  School,  New  York.  With  14  lithographic  plates  in  colors,  139  text- 
cuts,  and  III  pages  of  text.      Cloth,  $2.00  net.     In  Saunders   Hand- Atlases. 


Schaffer     and     Edgar's     Obstetric     Diagnosis     and 
Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and   Treatment.    By  Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery-,  Cornell  University 
Medical  School,  New  York.  With  122  colored  figures  on  56  plates,  38  text- 
cuts,  and  315  pages  of  text.      Cloth,   $3.00  net.      Saunders'  Hand- Atlases. 


Schaffer  and  Norris'  Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  Heidel- 
berg. Edited,  with  additions,  by  Richard  C.  Norris,  A.  M.,  M.  D., 
Gynecologist  to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text.  Cloth, 
^3.  ;o  net.      Li  Saunders'  Hand-Atlas  Series. 


Galbraith's  Four  Epochs  of  Woman's  Life 

New  (2d)  Editiot 

The  Four  Epochs  of  Woman's  Life :  A  Study  ix  Hygiene.  By  Ann/ 
M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of  Medicine,  etc, 
With  an  Introductor}-  Note  by  John  H.  Musser,  yi.  D.,  Universit)-  of 
Pennsylvania.      i2mo  of  247  pages.      Cloth,  Si.50  net. 

Birmingham  Medical  Review,  Englemd 

"  We  do  not,  as  a  rule,  care  for  medical  books  written  for  the  instruction  of  the  public 
But  we  must  admit  that  the  ad\ice  in  Dr.  Galbraith's  work  is,  in  the  main,  wise  anc 
wholesome." 


Garrigues'  Diseases  of  Women  Third  Editioi 

A  Text=Book  of  Diseases  of  Women.  By  Henry  J.  Garrigues,  M.  D. 
Gynecologist  to  St.  Mark's  Hospital,  New  York  Cit)'.  Octavo  of  756  pages 
illustrated.     Cloth,  $4. 50  net ;   Half  Morocco,  $6.00  net. 


GYNECOLOGY  AND    OBSTETRICS.  15 

Schaffer  and  Webster's 
Operative  Gynecology 


Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O.  Schaf- 
fer, of  Heidelberg.  Edited,  with  additions,  by  J.  Clarence  Webster, 
M.D.  (Edin.),  F.R.C.P.E.,  Professor  of  Obstetrics  and  Gynecology  in 
Rush  Medical  College,  in  affiliation  with  the  University  of  Chicago. 
42  colored  lithographic  plates,  many  text-cuts,  a  number  in  colors,  and 
138  pages  of  text.     In  Saunders'  Hand-Atlas  Series.    Cloth,  ^^3.00  net. 


Much  patient  endeavor  has  been  expended  by  the  author,  the  artist,  and  the 
lithographer  in  the  preparation  of  the  plates  of  this  atlas.  They  are  based  on 
hundreds  of  photographs  taken  from  nature,  and  illustrate  most  faithfully  the 
various  surgical  situations.  Dr.  Schaffer  has  made  a  specialty  of  demonstrating: 
by  illustrations. 

Medical  Record,  New  York 

"  The  volume  should  prove  most  helpful  to  students  and  others  in  grasping  details  usually 
to  be  acquired  only  in  the  amphitheater  itself." 

De  Lee*s 
Obstetrics  for  Nurses 


Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  M.D.,  Professor  of 
Obstetrics  in  the  Northwestern  University  Medical  School ;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.  i2mo  volume  of  508  pages, 
fully  illustrated.  Cloth,  ^2.50  net. 

THE  NEW  (4th)  EDITION 

While  Dr.  De  Lee  has  written  his  work  especially  for  nurses,  yet  the  prac- 
titioner will  find  it  useful  and  instructive,  since  the  duties  of  a  nurse  often  devolve 
upon  him  in  the  early  years  of  his  practice.  The  illustrations  are  nearly  all 
original,  and  represent  photographs  taken  from  actual  scenes.  The  text  is  the 
result  of  the  author's  many  years'  experience  in  lecturing  to  the  nurses  of  five 
different  training  schools. 

J.  Clifton  Edgeir.  M.  D., 

Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University ,  New  York. 
"  It  is  far  and  away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  io 
recommending  it  to  my  nurses,  and  students  as  well." 


1 6      SAUNDERS'  BOOKS  ON  GYNECOLOGY  AND   OBSTETRICS, 

American  Pocket  Dictionary  New  (8th)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Borland,  A.  M.,  M.  D.  677  pages,  ^i.oo  net;  with 
patent  thumb  index,  $1.2^  net. 

James  W.  Holland.  M.  D.. 

Professor  of  Medical   Chemistry   and    Toxicology   at  tke  Jefferson   Medical   College^ 

Pkiladelphia. 
"  I  am  struck  at  once  with  admiration  at  the   compact  size  and  attractive   exterior.     I 
can  recommend  it  to  our  students  without  reserve." 

Cra|(in*s  Gynecology.  New  (7th)  Edition 

Essentials  of  Gynecology.  By  Edwin  B.  Cragin,  M.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York.  Crown  octavo,  232  pages,  59  illustrations  Cloth,  ^i.oo 
net.     In  Saunders'   Question- Compend  Series. 

The  Medical  Record,  New  York 

"A  handy  volume  and  a  distinct  improvement  oi  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

Ashton*S    Obstetrics.  New  (7th)  Edition 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Revised  by  John  A.  McGlinn,  M.  D.,  Assistant  Professor 
of  Obstetrics  in  the  Medico-Chirurgical  College  of  Philadelphia. 
i2mo  of  287  pages,  109  illustrations.  Cloth,  ^$1.00  net.  In  Saunders' 
Question-  Compend  Series, 

Southern  Practitioner 

"An  excellent  little  volume  containing  correct  and  practical  knowledge.  An  admir 
able  compend,  and  the  best  condensation  we  have  seen." 

Barton  and  Wells*  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfrei 
M.  Barton,  M.  D.,  Assistant  to  Professor  of  Materia  Medica  anc 
Therapeutics,  Georgetown  University,  Washington,  D.  C. ;  anc 
Walter  A.  Wells,  M.  D.,  Demonstrator  of  Laryngology,  George^ 
town  University,  Washington,  D.  C.  i2mo  of  534  pages.  FleX' 
ible  leather,  ;^2.50  net ;  with  thumb  index,  ;^3.oo  net. 

Macfarlane's   Gynecology  for  Nurses  second  Editioi 

A  Reference  Hand-Book  of  Gynecology  for  Nurses.  By  Cath 
arine  Macfarlane,  M.  D.,  Gynecologist  to  the  Woman's  Hospital  o\ 
Philadelphia.  32mo  of  150  pages,  with  70  illustrations.  FlexibL 
leather,  $1.25  net. 

A.  M.  Seabrook,  M.  D., 

Woma7is  Medical  College  of  Philadelphia. 

"  It  is  a  most  admirable  little  book,  covering  in  a  concise  but  attractive  way  the  subiec 
from  the  nurse's  standpoint." 


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